scholarly journals Ethical analysis examining the prioritisation of living donor transplantation in times of healthcare rationing

2022 ◽  
pp. medethics-2021-107574
Author(s):  
Sanjay Kulkarni ◽  
Andrew Flescher ◽  
Mahwish Ahmad ◽  
George Bayliss ◽  
David Bearl ◽  
...  
Keyword(s):  
Health Systems ◽  
Living Donor ◽  
Resource Constraints ◽  
Standards Of Care ◽  
Living Donation ◽  
Living Donor Transplantation ◽  
Liver And Kidney ◽  
Exposure Risks ◽  
Healthcare Rationing ◽  
End Stage

The transplant community has faced unprecedented challenges balancing risks of performing living donor transplants during the COVID-19 pandemic with harms of temporarily suspending these procedures. Decisions regarding postponement of living donation stem from its designation as an elective procedure, this despite that the Centers for Medicare and Medicaid Services categorise transplant procedures as tier 3b (high medical urgency—do not postpone). In times of severe resource constraints, health systems may be operating under crisis or contingency standards of care. In this manuscript, the United Network for Organ Sharing Ethics Workgroup explores prioritisation of living donation where health systems operate under contingency standards of care and provide a framework with recommendations to the transplant community on how to approach living donation in these circumstances.To guide the transplant community in future decisions, this analysis suggests that: (1) living donor transplants represent an important option for individuals with end-stage liver and kidney disease and should not be suspended uniformly under contingency standards, (2) exposure risk to SARS-CoV-2 should be balanced with other risks, such as exposure risks at dialysis centres. Because many of these risks are not quantifiable, donors and recipients should be included in discussions on what constitutes acceptable risk, (3) transplant hospitals should strive to maintain a critical transplant workforce and avoid diverting expertise, which could negatively impact patient preparedness for transplant, (4) transplant hospitals should consider implementing protocols to ensure early detection of SARS-CoV-2 infections and discuss these measures with donors and recipients in a process of shared decision-making.

Increasing the Rate of Living Donor Kidney Transplantation in New Zealand: Developing an Evidence Base

2021 ◽  
Author(s):  
◽  
Paula Marie Martin
Keyword(s):  
Kidney Transplantation ◽  
New Zealand ◽  
Living Donor ◽  
Living Donation ◽  
Donor Kidney ◽  
Living Donor Kidney Transplantation ◽  
Living Donor Transplantation ◽  
End Stage ◽  
Donor Kidney Transplantation ◽  
Living Donor Kidney

<p>Increasing numbers of New Zealanders are experiencing end-stage renal failure, requiring kidney transplantation or dialysis. A transplant from a living kidney donor is the preferred treatment, offering better quality of life than dialysis, and greater life expectancy and cost-effectiveness than dialysis and deceased donor transplantation. Living donor transplant rates in New Zealand have plateaued and may even be declining at a time when many comparable countries are experiencing sustained increases. Viewing this issue as a complex policy problem, this research aimed to identify how rates of living donor kidney transplantation could be increased in New Zealand. Based on Walt and Gilson’s health policy triangle, which suggests that understanding policy issues requires attention not only to content (policy options) but also processes, contextual issues and actors, this research asked firstly, what the barriers are for patients in the journey to living donor transplantation, and secondly, why greater attention has not been paid to how to increase current rates, given evidence of better outcomes for patients and cost-effectiveness.  The research took a patient-centred, systems perspective and used a pragmatic, interdisciplinary, mixed-methods research design. Methods included a survey of kidney transplant waiting-list patients; interviews with patients, renal health professionals and key informants; document analysis; and a survey of health managers. A Five-Stage Model of the living donor kidney transplant process was developed to map specific barriers in the journey to transplantation and Kingdon’s multiple streams agenda-setting model was used to examine the issue of why so little attention had been paid to living donor kidney transplantation in New Zealand.  The research found that, in common with patients elsewhere, New Zealand patients are not systematically informed about living donor transplantation, would like to receive a transplant but have concerns about health and financial impacts on donors, and face challenges in approaching people in their networks about living donation. Incompatibility and medical unsuitability are major barriers for potential donors who do come forward. Issues with existing service models, configuration of key roles in transplant services, and delays in donor work-up processes are all evident. Perceived ethical constraints may limit how willing health professionals are to promote living donation, requiring both potential recipients and donors to be very proactive to successfully navigate the living donation process.  There has been political will to address organ shortages in the past but there has been little focus specifically on live donation. An absence of feasible and acceptable options for decision-makers to consider, crowding-out by demand for dialysis services, lack of leadership, absence of an effective advocate, and issues in funding and accountability arrangements may all have contributed to why live kidney transplantation has not had more prominence on the policy agenda in New Zealand in recent years.  Overall, the research concludes that policy and practice in the wider system are not adequately oriented to supporting living donor kidney transplantation as the preferred treatment for end-stage renal failure. A comprehensive national strategy for increasing New Zealand’s rate is recommended.</p>

Increasing the Rate of Living Donor Kidney Transplantation in New Zealand: Developing an Evidence Base

2021 ◽  
Author(s):  
◽  
Paula Marie Martin
Keyword(s):  
Kidney Transplantation ◽  
New Zealand ◽  
Living Donor ◽  
Living Donation ◽  
Donor Kidney ◽  
Living Donor Kidney Transplantation ◽  
Living Donor Transplantation ◽  
End Stage ◽  
Donor Kidney Transplantation ◽  
Living Donor Kidney

<p>Increasing numbers of New Zealanders are experiencing end-stage renal failure, requiring kidney transplantation or dialysis. A transplant from a living kidney donor is the preferred treatment, offering better quality of life than dialysis, and greater life expectancy and cost-effectiveness than dialysis and deceased donor transplantation. Living donor transplant rates in New Zealand have plateaued and may even be declining at a time when many comparable countries are experiencing sustained increases. Viewing this issue as a complex policy problem, this research aimed to identify how rates of living donor kidney transplantation could be increased in New Zealand. Based on Walt and Gilson’s health policy triangle, which suggests that understanding policy issues requires attention not only to content (policy options) but also processes, contextual issues and actors, this research asked firstly, what the barriers are for patients in the journey to living donor transplantation, and secondly, why greater attention has not been paid to how to increase current rates, given evidence of better outcomes for patients and cost-effectiveness.  The research took a patient-centred, systems perspective and used a pragmatic, interdisciplinary, mixed-methods research design. Methods included a survey of kidney transplant waiting-list patients; interviews with patients, renal health professionals and key informants; document analysis; and a survey of health managers. A Five-Stage Model of the living donor kidney transplant process was developed to map specific barriers in the journey to transplantation and Kingdon’s multiple streams agenda-setting model was used to examine the issue of why so little attention had been paid to living donor kidney transplantation in New Zealand.  The research found that, in common with patients elsewhere, New Zealand patients are not systematically informed about living donor transplantation, would like to receive a transplant but have concerns about health and financial impacts on donors, and face challenges in approaching people in their networks about living donation. Incompatibility and medical unsuitability are major barriers for potential donors who do come forward. Issues with existing service models, configuration of key roles in transplant services, and delays in donor work-up processes are all evident. Perceived ethical constraints may limit how willing health professionals are to promote living donation, requiring both potential recipients and donors to be very proactive to successfully navigate the living donation process.  There has been political will to address organ shortages in the past but there has been little focus specifically on live donation. An absence of feasible and acceptable options for decision-makers to consider, crowding-out by demand for dialysis services, lack of leadership, absence of an effective advocate, and issues in funding and accountability arrangements may all have contributed to why live kidney transplantation has not had more prominence on the policy agenda in New Zealand in recent years.  Overall, the research concludes that policy and practice in the wider system are not adequately oriented to supporting living donor kidney transplantation as the preferred treatment for end-stage renal failure. A comprehensive national strategy for increasing New Zealand’s rate is recommended.</p>

Adult-to-Adult Living-Donor Liver Transplantation

Swiss Surgery ◽  
2003 ◽  
Vol 9 (5) ◽  
pp. 227-236 ◽  
Author(s):  
Majno ◽  
Mentha ◽  
Berney ◽  
Bühler ◽  
Giostra ◽  
...  
Keyword(s):  
Liver Transplantation ◽  
Living Donor ◽  
Living Donor Liver Transplantation ◽  
Therapeutic Option ◽  
Donor Liver ◽  
Donor Liver Transplantation ◽  
Multidisciplinary Program ◽  
First Case ◽  
Living Donor Transplantation ◽  
The Right

Living donor liver transplantation is a relatively new procedure in which the right side of the liver is harvested in a healthy donor and transplanted into a recipient. After the first case in 1994, over 3000 cases have been done worldwide. This review summarizes the reasons why the procedure is needed, describes its main technical aspects, highlights the boundaries in which it can be done safely, summarizes the current experience worldwide and describes the main points of the program in our unit. We argue that living-donor transplantation is a viable alternative to a long time on the waiting list for several patients, and it can be performed safely and successfully provided that all precautions are undertaken to minimize the risks in the donor and to increase the chances of a good outcome in the recipients. If these prerequisites are met, and within the framework of a structured multidisciplinary program, we believe that living-donor liver transplantation should be funded by health insurances as a recognized therapeutic option.

scholarly journals Outcomes in Living Donor Kidney Transplantation: The Role of Donor’s Kidney Function

2021 ◽  
pp. 1-11
Author(s):  
Massimo Torreggiani ◽  
Ciro Esposito ◽  
Elena Martinelli ◽  
Thomas Jouve ◽  
Antoine Chatrenet ◽  
...  
Keyword(s):  
Kidney Transplant ◽  
Kidney Function ◽  
Living Donor ◽  
Graft Function ◽  
Kidney Graft ◽  
Donor Kidney ◽  
Transplant Center ◽  
Function Correlation ◽  
End Stage ◽  
Living Donor Kidney

<b><i>Introduction:</i></b> Living donor kidney transplant (LDKT) is one of the best therapeutic options for end-stage kidney disease (ESKD). Guidelines identify different estimated glomerular filtration rate (eGFR) thresholds to determine the eligibility of donors. The aim of our study was to evaluate whether pretransplant donor eGFR was associated with kidney function in the recipient. <b><i>Methods:</i></b> We retrospectively studied LDKT recipients who received a kidney graft between September 1, 2005, and June 30, 2016 in the same transplant center in France and that had eGFR data available at 3, 12, 24, and 36 months posttransplant. <b><i>Results:</i></b> We studied 90 donor-recipient pairs. The average age at time of transplant was 51.47 ± 10.95 for donors and 43.04 ± 13.52 years for recipients. Donors’ average eGFR was 91.99 ± 15.37 mL/min/1.73 m<sup>2</sup>. Donor’s age and eGFR were significantly correlated (<i>p</i> &#x3c; 0.0001, <i>r</i><sup>2</sup> 0.023). Donor’s age and eGFR significantly correlated with recipient’s eGFR at 3, 12, and 24 months posttransplant (age: <i>p</i> &#x3c; 0.001 at all intervals; eGFR <i>p</i> = 0.001, 0.003, and 0.016, respectively); at 36 months, only donor’s age significantly correlated with recipient’s eGFR. BMI, gender match, and year of kidney transplant did not correlate with graft function. In the multivariable analyses, donor’s eGFR and donor’s age were found to be associated with graft function; correlation with eGFR was lost at 36 months; and donor’s age retained a strong correlation with graft function at all intervals (<i>p</i> &#x3c; 0.001). <b><i>Conclusions:</i></b> Donor’s eGFR and age are strong predictors of recipient’s kidney function at 3 years. We suggest that donor’s eGFR should be clinically balanced with other determinants of kidney function and in particular with age.

scholarly journals Preventing ethics dumping: the challenges for Kenyan research ethics committees

2020 ◽  
pp. 174701612092506
Author(s):  
Kate Chatfield ◽  
Doris Schroeder ◽  
Anastasia Guantai ◽  
Kirana Bhatt ◽  
Elizabeth Bukusi ◽  
...  
Keyword(s):  
Research Ethics ◽  
Resource Constraints ◽  
Ethics Committees ◽  
Shared Responsibility ◽  
Standards Of Care ◽  
Primary Data ◽  
Research Ethics Committees ◽  
Governance System ◽  
Middle Income ◽  
System Resource

Ethics dumping is the practice of undertaking research in a low- or middle-income setting which would not be permitted, or would be severely restricted, in a high-income setting. Whilst Kenya operates a sophisticated research governance system, resource constraints and the relatively low number of accredited research ethics committees limit the capacity for ensuring ethical compliance. As a result, Kenya has been experiencing cases of ethics dumping. This article presents 11 challenges in the context of preventing ethics dumping in Kenya, namely variations in governance standards, resistance to double ethics review, resource constraints, unresolved issues in the management of biological samples, unresolved issues in the management of primary data, unsuitable informed consent procedures, cultural insensitivity, differing standards of care, reluctance to provide feedback to research communities, power differentials which facilitate the exploitation of local researchers and lack of local relevance and/or affordability of the resultant products. A reflective approach for researchers, built around the values of fairness, respect, care and honesty, is presented as a means of taking shared responsibility for preventing ethics dumping.

Renal transplantation in the first year of life: the treatment of choice for infants with end-stage renal disease.

1992 ◽  
Vol 2 (12) ◽  
pp. S228
Author(s):  
J S Najarian ◽  
P S Almond ◽  
M Mauer ◽  
B Chavers ◽  
T Nevins ◽  
...  
Keyword(s):  
Renal Failure ◽  
Renal Transplantation ◽  
Survival Rate ◽  
Living Donor ◽  
Patient Survival ◽  
First Year ◽  
End Stage Renal Failure ◽  
End Stage ◽  
First Year Of Life ◽  
Patient Survival Rate

The treatment of choice for end-stage renal failure within the first year of life is controversial. Between September 1970 and February 1991, we performed 28 kidney transplants (27 primary, 1 retransplant, 23 living donor, 5 cadaver) in infants less than 1 yr of age (mean, 7 +/- 2 months; range, 6 wk to 12 months). The 1-yr patient survival rate for living donor recipients was 100% versus 20% for cadaver recipients (P = 0.0001). The 1-yr graft survival rate for living donor recipients was 96% versus 20% for cadaver recipients (P = 0.001). The 1-yr patient survival rate for cyclosporin A (CSA) recipients (N = 12) was 100% versus 75% for non-CSA recipients (P = 0.03). The 1-yr graft survival rate for CSA recipients was 92% versus 75% for non-CSA recipients (P = 0.08). There was no difference in the number of rejection episodes or serum creatinine levels in CSA versus non-CSA recipients. Compared with pretransplant values, the mean posttransplant standard deviation scores (SDS) for height (N = 18), weight (N = 22), and head circumference (N = 8) improved: height SDS from -1.9 to -1.5 (not significant); weight SDS from -2.5 to 0.6 (P less than 0.0005); head circumference SDS from -2.0 to -0.7 (P = 0.01). Because no other renal replacement therapy can match these results, we conclude that renal transplantation is the treatment of choice for infants with end-stage renal failure.

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