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Why Living Kidney Donation?

Someone who has kidney failure--often called End Stage Renal Disease (ESRD)--has three options for treatment: dialysis, a transplant from a deceased person, or a transplant from a living person.  Here are a couple of web sites to learn more about dialysis: National Kidney Foundation and the "I Hate Dialysis" web site.  You can learn about deceased donor transplants here: Wikipedia--Organ Transplant and OrganDonor.gov.

Why is living kidney donation a consideration? First, dialysis is only a temporary solution. While someone can remain on dialysis for many years, it is not a cure and it is time consuming with treatments as frequent as three times a week for four hours each time. Transplantation from a deceased donor is a preferred alternative, but the number of donated organs is not keeping up with demand. United Network of Organ Sharing (UNOS), the organization responsible for allocating donated organs for transplant, reports there are more than 80,000 people waiting for a kidney transplant, and that number increases daily. Yet, in 2009 there were only 10,442 kidneys donated from deceased donors. Consequently, living donation is seen as a way to address the gap. 

There are several reasons why living kidney donation is an important consideration:

• Transplantation has been shown to be less costly than dialysis over the long run.

• The waiting time for a transplant recipient can be significantly reduced.

• The procedure can be scheduled at a time convenient for both the donor and recipient.

• The quality of the donated organ tends to be superior to organs from deceased donors.

All of these factors have yielded positive results for recipients. There is less rejection and lower doses of anti-rejection drugs. The transplanted kidney, or "graft," has better odds of surviving if from a living donor, as show in the following UNOS data for kidney transplants in the U.S from 1996 to 2006:

Types of Living Donation

There are different types of living donation, which generally are determined by two factors--(1) whether the donor and recipient are biologically related and (2) whether the donor is directing the donation. "Directing" means the donor identifies the specific person to whom he or she is donating. The different forms of donation and the terminology used to describe them are as follows:

• Living related donation: the living donor directs the donation to a specific recipient who is a blood relative (such as a parent, child, or sibling). Looking at UNOS data for living kidney donations made since 1988, about 75% were living related donations.

• Living unrelated donation: the living donor directs the donation to a specific recipient who is not a blood relative (such as a spouse, a friend, or co-worker). About 24% of living kidney donations since 1988 were living unrelated donations.

• Living non-directed donation: the living donor does not direct the donation. Instead, the recipient is selected from a list of compatible people on a kidney waiting list. This form of donation is also sometimes called "anonymous" donation because the donor and recipient do not necessarily ever meet. Only about 1% of living kidney donations are of this type.

Another type of living donation is called paired exchange. In this situation, there are at least two donor/recipient pairs where the donors are not able to donate to the directed recipients because of blood types that aren't compatible or because of a positive crossmatch. (See LDO kidney page 4 for more on blood and tissue compatibility.) However, the donor in one pair is compatible with the recipient of the other pair, and vice versa, allowing the donor of one pair to donate to the recipient of the other pair.  In some cases, more than two donor/recipient pairs are linked in an extended "chain" of donation.

Here's an example of a paired exchange. Assume in the first donor/recipient pair, the donor, Jim, is blood type A and the person he'd like to donate to, Lisa, is blood type B. Jim can't donate to Lisa because they have incompatible blood types. In the second pair, the donor, Niki, is blood type B and she'd like to donate to Mike, but he's blood type A. They are incompatible. Paired exchange provides the solution: Jim donates to Mike (both blood type A), and Niki donates to Lisa (both blood type B). This form of living donation is rare, but organizations have been formed recently to facilitate the matching of donor/recipient pairs. As a result, the number of paired exchanges is increasing rapidly. More information on the paired exchange organizations can be found on the LDO kidney links page.

Who Donates?

Currently there are about 6,000 living kidney donors each year. They come from all walks for life and locations. Here is a summary of the demographic characteristics of U.S. living kidney donors who donated between 1988 and February 2008:

• Most (45%) were between the ages of 35 and 49.

• 71% were white, 13% black, 12% Hispanic, and 2% Asian.

• The majority (58%) of donors were female.

• 45% had type O blood, 38% type A, 13% type B, and 4% type AB.
  
  Source: OPTN Data as of February 28, 2008

A Brief History of Living Kidney Donation

Living kidney donation began in 1954 with the donation by Ronald Herrick to his identical twin, Richard. The procedure was performed by Dr. Joseph E. Murray at Peter Bent Brigham Hospital in Boston, MA. Being identical twins was an advantage because there was no risk of rejection--the tissue types were identical. The procedure was a success, and Richard lived a healthy life until his death eight years later of causes unrelated to the donation. Ronald Herrick passed away in 2010 at age 79 following complications from heart surgery.

Living kidney donation is now commonplace. In fact, kidney transplantation is no longer considered experimental and is routinely covered by medical insurance programs.

In 1995, a new surgical procedure using laparoscopic techniques to procure the kidney from the donor was pioneered. This less invasive procedure, called "laparoscopic nephrectomy," has replaced "open nephrectomy" as the most common surgical procedure because of more positive outcomes for the donor.

An emerging ethical issue is the growth in the number of donations where this is no biological or emotional tie between the donor and recipient. The number of these donations has been increasing since 2000, facilitated by the development of more powerful anti-rejection drugs, which has reduced the importance of tissue matching and, therefore, the need for close biological ties. It has also been aided by the use of web sites that connect potential donors with potential recipients even though the individuals are essentially strangers. On one side of the issue, such donors increase the number of transplants at a time when they are desperately needed. Some argue these donors also receive personal benefit and increased self-esteem from donating. On the other side of the issue, some ethicists and medical professionals are suspicious of people who meet over the Internet, assuming the probability of illegal compensation or coercion is higher. Ethicists are also concerned that solicitation of an unrelated person to donate bypasses the safeguards built into the current organ allocation system. In response to these concerns, some transplant centers do not allow unrelated living donor transplants unless there is a biological or emotional relationship between the donor and recipient. People who are willing to donate anonymously or who met recipients on the Internet have been prevented from donating at these transplant centers. 

An experimental development in living donation is the use of the donor's bone marrow to minimize or even eliminate the need for anti-rejection drugs by the recipient. The technique, called chimerism, has the donor first donating bone marrow, which is used to change the recipient's immune system. The donor then donates a kidney. Anti-rejection drugs are used initially, but eventually the recipient does not need to take those drugs. This process was tried on five patients. The transplant teams provided an update in January 2008, five years after the procedure, reporting that one patient rejected the kidney, and the other four patients have kept the donated kidney without the use of anti-rejection drugs. Oddly, the authors of the report did not share any information whatsoever on the fate of the five donors who provided the bone marrow and kidneys essential to the procedure. This process is still considered experimental and is not available.

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