END-STAGE RENAL DISEASE
• Complete and Irreversible damage to both kidneys • Fatal disease
END-STAGE RENAL DISEASE: TOP 3 CAUSES
• Diabetic nephropathy • Chronic glomerulonephritis • Hypertensive nephrosclerosis
RENAL REPLACEMENT THERAPY
• Hemodialysis • Peritoneal dialysis • Kidney transplantation
ADVANTAGES OF KIDNEY TRANSPLANTATION
• Better survival • Better quality of life • More cost effective in the longterm
KIDNEY TRANSPLANTATION
DONOR
RECIPIENT
• Transplant can’t happen without him
KIDNEY TRANSPLANTATION
DONOR
• Deceased or living
• If living, related or unrelated
THE LIVING KIDNEY DONOR
• Unique because he is the only “patient” who undergoes surgery when he is
healthy and the purpose of which is solely
the benefit of another person
THE LIVING KIDNEY DONOR: RISKS AND BENEFITS
The ethical underpinnings of living donor KT are built upon
• the recognition of minimal risk to a living
kidney donor and • the consideration that it is an act of altruism
PRINCIPLES OF LIVE KIDNEY DONATION
Person who gives consent to be a donor should be • Competent • Willing to donate • Free of coercion • Medically and psychosocially suitable • Fully informed of risks and benefits as a donor • Fully informed of risks, benefits and alternative treatment available to recipient
The consensus statement of the Amsterdam Forum on the Care of the Live Kidney Donor. Transplantation 2004. 78:491-92
MAJOR PSYCHOSOCIAL CONTRAINDICATIONS TO LIVE KIDNEY DONATION
• Ongoing psychiatric or substance abuse problems • Presence of major financial stressors that could either have a coercive effect on the donors decision to donate or significantly worsen as a result of donation and any medical complications • Evidence that the prospective donor has experienced undue pressure or coercion from others to donate
The consensus statement of the Amsterdam Forum on the Care of the Live Kidney Donor. Transplantation 2004.
MAJOR PSYCHOSOCIAL CONTRAINDICATIONS TO LIVE KIDNEY DONATION
• A limited understanding or capacity to understand the donor’s own or the kidney transplant candidate’s risks and benefits • Ambivalence about proceeding with the donation
The consensus statement of the Amsterdam Forum on the Care of the Live Kidney Donor. Transplantation 2004.
THE PHILIPPINE SITUATION
NUMBER OF KIDNEY TRANSPLANTS INCREASING EVERY YEAR
800 700 611 690
600
500 470 400 306 276 186 157 100 124 208 263 420
300
200
0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Philippine Renal Disease Registry
650 600 550 500 450 400
KIDNEY TRANSPLANTS FROM LIVING DONORS MARKEDLY OUTNUMBER TRANSPLANTS FROM DECEASED DONORS
LIVING DONOR
598
654
413
350 300 250
413
296 250 253
200 150 100 50 0 1999 2000
189
DECEASED DONOR
6 17 6
2001
10
2002
7
2003
15
36 13
2004
2005
2006
Philippine Renal Disease Registry
AMONG LIVING DONORS, THERE IS AN INCREASING NUMBER OF NON-RELATED DONORS
500
473
450 400 350 300 250
449
NON-RELATED
260 228
RELATED
181
200 150
163 153 157 126 95 86 52 128
185 153 149
100 50 0
1999
2000
2001
2002
2003
2004
2005
2006
Philippine Renal Disease Registry
INCREASE IN NUMBER OF LNRDS ALMOST MATCHED BY INCREASE IN NUMBER OF FOREIGN REICIPIENTS
500 450 400 350 300
NUMBER OF NON-RELATED DONORS 73% INCREASE
260 228
473 449
250 200 150 100
NUMBER OF FOREIGN RECIPIENTS 62% INCREASE
163
95
50
86 52
0 1999 2000 2001 2002 2003 2004 2005 2006
Philippine Renal Disease Registry
2002: DOH AO 124
• Philippine Organ Donation Program was created
• Created a National Transplant Ethics Committee • Created a Kidney Donor Monitoring Unit • Tasked the Bureau of Health Facilities and Services with monitoring of transplant facilities • “Sale and purchase of kidney organs by kidney vendors prohibited” • Implementing guidelines set a cap of 10% on kidney transplant for foreigners
LEGAL FRAMEWORK
2003 RA 9208 Anti Trafficking in Persons Act
WORLD KIDNEY DAY PROJECT MARCH 2008
The Philippine Society of Nephrology conducted a one-day clinic for kidney
donors on March 15, 2008 at the
Magsaysay Memorial Medical Center in Lopez, Quezon
MEDICAL MISSION FOR KIDNEY DONORS - LOPEZ, QUEZON
• 109 kidney donors were seen. 2 were related donors. 107 were non-related donors
• All underwent physical examination, blood test for CBC and serum creatinine, urine dipstick for blood, protein, and signs of infection.
• All were interviewed by social workers of the DSWD.
• All were asked to watch a video on how to protect their general health and their remaining kidney • All were given a grocery package and medications were given if necessary
PROFILE OF 107 KIDNEY VENDORS
• All were male
• Average time elapsed from operation – 16 months • Average age – 29 years old • 66% had not reached high school • 16% were unemployed prior to operation
PROFILE OF 107 KIDNEY VENDORS
• Most were farmers or tricycle drivers
• Average household monthly income – P3600 • Average amount received for the kidney – P112,000
PERCEPTIONS OF 107 KIDNEY VENDORS
• 45% felt physically weaker after operation
• 74% felt they did not improve their lives economically • 79% felt their capacity to work was reduced • 31% were unemployed at the time of the survery
PERCEPTIONS OF 107 KIDNEY VENDORS
• 71% would not sell their kidney if given another chance • 96% would not recommend that others sell their kidney
MEDICAL FINDINGS IN 107 KIDNEY VENDORS
• Average serum creatinine 1.4 mg/dl • Average estimated creatinine clearance 66 ml/min
• 16% had blood pressure at least 140/90 mm Hg
• Macroalbuminuria present in 2.8%
PRE-SCREENING OF KIDNEY DONORS
• Should have no hypertension • Should have normal kidney function • Should have no protein in the urine
2008 DOH ISSUES NEW AO CONCERNING LIVING NON-RELATED KIDNEY DONORS
PHILIPPINE SOCIETY OF NEPHROLOGY POSITION STATEMENT
The AO is the wrong response to the problem.
2002: DOH AO 124 Problems with implementation
• Created a National Transplant Ethics Committee • 2007 Program Implementation Review said “The organ donation program of the country has no mechanism to adequately enforce ethical guidelines on accredited facilities
2002: DOH AO 124 Problems with implementation
• Created a Kidney Donor Monitoring Unit • Only 53% follow-up reported in 2007
2002: DOH AO 124 Problems with implementation
• Tasked the Bureau of Health Facilities and Services with monitoring of transplant facilities • 2007 Program Implementation Review said “the BHFS is said to be unable to enforce rules due to the lack of capacity and ability to monitor accredited facilities”
2002: DOH AO 124 Problems with implementation
• Implementing guidelines set a cap of 10% on kidney transplant for foreigners • Almost all hospitals performing kidney transplants have violated this and no sanctions have been imposed
2002: DOH AO 124 Problems with implementation
• “Sale and purchase of kidney organs by kidney vendors prohibited” • Several exposes have shown that sale of kidneys rampant
The AO is deceptive.
The AO contradicts itself.
The AO is opposed by local and international health organizations.
Thank you!