Kidney-Donor Exchange Proposed

June 11, 1997

In order to increase living-donor kidney transplants, a team of physicians from the University of Chicago has proposed to initiate a "paired kidney exchange" program and study its ethical implications The program would allow two people who need kidney transplants and have willing but incompatible donors to exchange donor kidneys.

The carefully designed protocol and consideration of its ethical consequences are offered for public comment in the June 12 issue of the New England Journal of Medicine.

"We wanted to devise an ethical framework for a fair and voluntary exchange in order to make the best use of a scarce resource," says ethicist Lainie Friedman Ross, M.D., Ph.D., assistant professor of pediatrics and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago Medical Center and first author of the study. "At the same time, we wanted to minimize the risk of coercing donors and to ensure that this exchange does not promote the commercialization of organ donation.

"We think the proposed protocol meets these criteria," adds Ross, "but by seeking public and professional criticism of the proposal before performing the procedure -- an approach to the ethics of innovation previously developed at the University of Chicago -- we hope to refine the process and gauge public acceptance of this imaginative project."

To make it easier for the general public to comment, the authors have created an open web site for responses, suggestions or critiques at http://uhs.bsd.uchicago.edu/kidneyxch.htm

In 10 to 20 percent of cases at the University of Chicago Hospitals, patients who need a kidney transplant have family or friends who agree to donate, but the willing donor is found to be biologically unsuited for that specific recipient. In the past, this meant a recipient had to wait in line for years, dependent on dialysis, until a kidney from a cadaver donor became available.

In December, 1996, 34,550 people in the United States were on the United Network for Organ Sharing (UNOS) waiting list for a kidney. Last year 1,814 died waiting.

Success rates with living kidney donors (around 70% graft survival five years after surgery) exceed those using cadaveric donors (58%). Until recently, living-donor kidney transplantation was confined to genetically similar relatives. Now, improved immunosuppression allows increased use of biologically dissimilar but emotionally related kidney donors, such as a spouse. Graft survival five years after surgery from unrelated living donors is about the same as from related but non-identical donors.

Despite improved medications, however, some donor-recipient pairs remain incompatible because of discordant blood types or antagonistic immune systems.

In this proposal, an incompatible donor could still contribute a kidney, but it would go instead to an unrelated second recipient. In exchange, the volunteer donor for the second recipient would contribute a kidney for transplantation to the first recipient. By exchanging donor kidneys, both recipients receive a timely transplant with a living, compatible kidney, circumventing the incompatibility with their own living donor.

Although medically feasible, a donor exchange creates unusual logistical and ethical challenges. For example, each set of transplants will require coordination of the evaluation and scheduling of four patients: two donors and two recipients. The surgical procedures will require the simultaneous efforts of four transplant teams in four operating rooms.

But the tactical concerns are dwarfed by the ethical challenges of ensuring informed consent and confidentiality for all four patients. In this pilot study, recipients and donors will be asked whether they would consider participation in this research protocol before any work-up as a direct donor has begun. Only if a recipient has no emotionally related match and a potentially willing exchange donor will the transplant team re-address the option of an exchange with the donor and recipient.

"Of utmost importance in this protocol is the protection of voluntary organ donors," explains E. Steve Woodle, M.D., senior author of the proposal and director of renal transplantation at the University of Chicago.

The physicians were concerned that the organ exchange might compromise the voluntary nature of kidney donation. To make certain that the donor's decision was voluntary, the researchers added a psychiatric evaluation to the protocol, providing one more opportunity to withdraw consent.

In order to ensure that one donor does not withdraw after the other has already entered surgery, both transplants will be performed simultaneously.

The authors predict that the kidney-exchange protocol will be "as ethically acceptable to donors and recipients as direct donation," and that success rates will equal those of direct donation to a spouse or friend.

If that is the case, however, they recommend that such protocols be restricted to major transplant centers, which have the capability to perform simultaneous transplants and the resources to ensure that patients give voluntary and informed consent. A nationwide registry may offer less protection to donors and complicate the timing of an organ exchange.

Additional authors include David Rubin, M.D., department of medicine; Mark Siegler, M.D., MacLean Center for Clinical Medical Ethics; nephrologist Michelle Josephson, M.D.; and Richard Thistlethwaite, M.D., Ph.D., section chief of transplantation, all from the University of Chicago. Web site prepared by Rubin and David Liebovitz, M.D.
-end-


University of Chicago Medical Center

Related Transplantation Articles from Brightsurf:

A revolutionary new treatment alternative to corneal transplantation
A new approach in ophthalmology that offers a revolutionary alternative to corneal transplantation has just been developed by researchers and clinicians in North America, Europe, and Oceania.

Fewer complications after organ transplantation
A large international study coordinated by University Hospital Regensburg and Charité - Universitätsmedizin Berlin has demonstrated the safety of new cell therapy approaches for use in kidney transplant recipients.

Elderly patients also benefit from kidney transplantation
So far, kidney transplantation has generally not been offered to elderly patients (>75 years) because of the perioperative risks.

New material will allow abandoning bone marrow transplantation
Scientists from the National University of Science and Technology 'MISIS' developed nanomaterial, which will be able to restore the internal structure of bones damaged due to osteoporosis and osteomyelitis.

Fewer medical tests -- timely listing for transplantation
Younger patients would benefit greatly from kidney transplantation. Their expected remaining lifetime may even be doubled by having a transplant.

Uterus transplantation -- ethically just as problematic as altruistic surrogacy
In 2014, the first child to have been gestated in a donated uterus was born.

Advancing transplantation: Hepatitis C-infected organs safe for transplantation when followed by antiviral treatment
Twenty patients at Penn Medicine have been cured of the hepatitis C virus (HCV) following lifesaving kidney transplants from deceased donors who were infected with the disease, according to a study published today in Annals of Internal Medicine.

Transplantation followed by antiviral therapy cured hepatitis C
Twenty patients who received kidneys transplanted from hepatitis C virus (HCV)-infected donors experienced HCV cure, good quality of life, and excellent renal function at one year.

The Journal of Heart and Lung Transplantation: 50 years of heart transplantation progress
This month marks the 50th anniversary of the world's first human heart transplant performed at Groote Schuur Hospital in Cape Town by South African surgeon, Christiaan Barnard.

Older donor lungs should be considered for transplantation
With a scarcity of lungs available for transplantation, the use of lungs from donors older than age 60 has been shown to achieve reasonable outcomes and should be considered as a viable option, according to research published online today in The Annals of Thoracic Surgery.

Read More: Transplantation News and Transplantation Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.