By: Paul Morrissey, MD, associate professor of surgery
Reginald Gohh, MD, associate professor of medicine
Division of organ transplantation,
Rhode Island Hospital and
Brown Medical School
The success of kidney transplantation has created an unprecedented demand for a limited supply of kidney donors. Despite aggressive public service and media efforts to increase the rate of cadaver organ donation, it is evident that the annual number of available deceased organ donors will never be sufficient to meet the demands of the ongoing organ shortage. Currently over 63,000 patients are registered on the national waiting list for a renal transplant and median waiting times for a kidney from a deceased donor now exceed three years in much of the country (1). Additionally, there appears to be a survival advantage for individuals transplanted either before or after a brief period of dialysis, thus stressing the importance of exploring all possible options for transplantation (2). To address this problem, the majority of transplant centers have relied on living donors as an important kidney source and nationally, living donors now provide 42% of all kidney transplants (1). In fact, for the past three years there have been more living donors in the United States than deceased donors.
Kidneys from live donors provide superior results to cadaver sources, regardless of the genetic relationship to the recipient (3-6). Furthermore, long-term studies demonstrate the relative safety of the living-donor operation, showing no impact on either longevity or quality of life for the donor (7-9). Thus, the current standard adopted by most transplant centers is to consider any adult as an organ donor who is motivated, competent, free of coercion, and medically and psychologically fit. Traditionally, these individuals have been intimately related to the identified recipient, either genetically or through an emotional bond. However, the success of kidney transplantation from a genetically unrelated living spouse or friend and the compelling need to provide for an ever-expanding waiting list have influenced transplant physicians to at least consider the requests of strangers wishing to make a gift through kidney donation.
About Altruistic Donations
From time to time, transplant centers and organ procurement organizations across the country receive inquiries from individuals seeking to donate a kidney to a stranger in need of a transplant. These donors are referred to as "altruistic" or "Good Samaritan donors." The stranger may "donate to the list" within a specific transplant center or region. The initial inquiry for a non-directed donation may be directed to:
a local transplant center (Rhode Island Hospital, 401-444-8345)
an organ procurement organization (New England Organ Bank, 800- 446-NEOB)
the National Kidney Foundation (http://www.kidney.org/transplantation/livingDonors/aboutHistory.cfm).
While formal efforts to recruit volunteers are not encouraged, individuals interested in altruistic kidney donation are invited to contact any of the above sources for further information and a screening questionnaire. A comprehensive information packet regarding the practice of living donation, including inclusion and exclusion criteria is available for potential donors at many transplant centers. Those who wish to explore non-directed donation should undergo an initial screening interview and meet with a nurse coordinator or physician at a transplant center.
The objective of the interview is to discuss in detail the donation process (including the pre-operative evaluation, the operation and associated risks, recovery time, potential long-term complications, and potential donor costs). The meeting also provides an opportunity to evaluate for the presence of medical and social contraindications to surgery and to evaluate the donor's motivation and ability to give an informed consent. The criteria for medical suitability for kidney donation makes no distinction between the altruistic and the emotionally/genetically-related donor, since the risks of surgery are independent of these relationships. However, increased emphasis is placed on the psychosocial evaluation of Good Samaritan donors. As opposed to related donors where the obvious rationale to donation is to improve the health of a person with whom they share a relationship, no such well-defined benefit can be ascribed to the altruistic donor. Such donor requests are referred for comprehensive psychiatric evaluation to ensure that the motives for donating are acceptable and realistic and exclude underlying major psychiatric illness.
Choosing the Recipient
Kidneys are allocated to patients on the waiting list based on the recipient waiting time and matching. This system provides an unbiased and objective means to identifying prospective recipients. Once the recipient is identified, both donor and recipient are given an opportunity to communicate before the transplant, if both parties so desire. Others have preferred to meet after the transplant surgery-often during the recovery days. Given the generosity of the Good Samaritan donor, we feel that it is within their right to request such a meeting if desired. Alternatively, if the donor prefers, complete anonymity can be maintained.
Attitudes toward the use of living donors for transplantation continue to evolve. Most centers support the use of living donors, because of the favorable risk-benefit ratio and its long-proven success. Widespread support also exists for renal transplantation from an emotionally related donor (spouse, friend, distant relative, in-law). However, the use of strangers as kidney donors has been far less common and perhaps under-utilized. The practice has gained support from both ethicists and the general public (11-13). Indeed, organ donation is an altruistic act and "altruism receives its highest expression in the absence of personal relationships." (14) In a recent poll, 80% of respondents supported kidney donation by strangers (15). Additionally, a surprising number of respondents answered favorably when asked if they would (24%) or probably would (21%) donate a kidney to a stranger in need for free (15). Although this remarkable response has not been realized in clinical practice (only a few hundred altruistic donations have actually taken place), it does underscore the resolve of the general public and does imply an underutilized resource for donor kidneys.
The National Kidney Foundation has established a system for addressing potential altruistic donors. A screening interview is arranged for potential donors in which preliminary information and contacts to local transplant centers are provided. The National Kidney Foundation web site (http://www.livingdonorsonline.org/kidney/kidneylinks.htm) includes material about this issue, although no attempts are made to actively solicit potential non-directed donors and relies on the individual to make the initial contact. Furthermore, an educational initiative is currently underway within the region to promote Good Samaritan donation at individual transplant centers.
In this way, we hope to positively influence centers with lingering doubts about the propriety of this practice to at least consider the option of altruistic donation. In so doing, the transplant community may not only honor the goals of those who wish to donate, but also provide an excellent opportunity to alleviate the ever-growing shortage of solid organs for transplantation.