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Clinical Crossroads | Clinician's Corner

Live Kidney Donation:  A 36-Year-Old Woman Hoping to Donate a Kidney to Her Mother

Martha Pavlakis, MD, Discussant
JAMA. 2011;305(6):592-599. doi:10.1001/jama.2011.56.
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Ms D, a healthy 36-year old-woman, wishes to donate a kidney to her mother, who has diabetes and end-stage renal disease. Ms D has been evaluated as a donor at another medical center and was told to lose weight and quit smoking. Evidence from cohort studies suggests that live kidney donation is a safe procedure in the short and long terms, although donor follow-up studies have often had incomplete data on limited populations. The benefits of live donation are mostly for the recipient, but kidney donors often have improved quality of life as a result of both their generous act and the improved health of the recipient. Evaluation and eligibility of live kidney donors and their short- and long-term risks are discussed.

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Ambivalence in a Potential Living Kidney Donor
Posted on February 5, 2011
John Henning Schumann, MD
MacLean Center for Clinical Medical Ethics, University of Chicago
Conflict of Interest: None Declared
Living organ donation is an unusual circumstance in medical practice: Appropriately screened donors are harmed for the sake of helping another individual; this is a now-conventional and accepted violation of the Hippocratic tenet to do no harm. Like Ms. D, most potential living kidney donors know or are related to their recipients.(1) Personal knowledge of a close relation's suffering is usually what draws donors into considering making a "gift of life."(2) The risks of donation, though real, are small: There are the risks of anesthesia, bleeding, infection, and eventual chronic kidney disease and even renal failure.(3) Yet for what amounts to an inconvenience and several weeks out of one's normal routine, potential donors get the benefit of living out the "golden rule."
The emotional risks of donation are more challenging to enumerate: there is the possibility of harm from physical pain, post-operative and post-anesthesia depression, and the potential for void from missing an organ or feeling a lack of appreciation on behalf of the recipient.(4) Detecting coercion in the evaluation of a potential donor, while a contraindication, is impossible to detect with certainty. And of course under federal law, compensation of any form is illegal.(5)
Transplant programs create their own criteria for donor suitability. Most presume no existing kidney disease, diabetes, hypertension, renal masses or stones. Since 2007, CMS has mandated that programs have advocate teams to evaluate every potential living donor for coercion, informed consent, and possibly to provide a medical excuse in the event that a donor develops "cold feet."(6)
The medical criteria are strict and definite. Weight and smoking are remediable, but proteinuria, or any other evidence of kidney disease is not. Potential donors often "vote with their feet" by not following up with appointments or keeping the transplant center apprised of their intentions. Rare is the patient who makes it to the donor advocate team evaluation and then opts out.
Ms. D sounds slightly ambivalent in her desire to donate.(7) As one of six daughters, it seems reasonable that one would step forward to help the mother. Yet only 2 of 6 children are tissue matches, and of the two, only Ms. D is medically safe to donate, albeit for her smoking the need to lose weight. She can set these as external goals, which if she is unable to meet might reflect on an inner desire not to donate.
Further, Ms. D. needs to consider her socioeconomic situation. She is a nursing student; will her program tolerate an extended absence? Is she employed while in school? What are the financial consequences of being off of work? Who will care for her 10 year-old son while she is in the hospital and convalescing? Is the boy's father involved in the decision-making?
In the end, Ms. D must reconcile her own desire to help her ailing mother with the reality of living donor nephrectomy. Fortunately we now have more than two decades worth of data to suggest that her lifetime risk of progressing to end stage renal disease is no more so than the general population.(8) If her concerns over smoking and weight can be successfully managed, she will be a suitable candidate, one that any living donor program would be happy to have. As a future health care worker, Ms. D would be an exemplary role model to future colleagues and patients.
________________________________________
1 Mandelbrot DA, Pavlakis M, Danovitch GM et al. The medical evaluation of living kidney donors: A survey of US transplant centers. Am J Transplant 2007; 7: 2333-2343.
2 Steiner R, Matas AJ. First things first: Laying the ethical and factual groundwork for living kidney donor selection standards. Am J Transplant 2008; 8: 930-932
3 Ibrahim HN, Foley R, Tan L et al. Long term consequences of kidney donation. New Engl J Med, 2009; 360, 459-469.
4 Clemens KK, Thiessen-Philbrook H, Parikh CR et al. Psychosocial health of living kidney donors: a systematic review. Am J Transplant 2006; 6: 2965-2977.
5 National Organ Transplant Act (1984). Accessed at http://optn.transplant.hrsa.gov/policiesAndBylaws/nota.asp , on February 4, 2011.
6 Ross LF. What the medical excuse teaches us about the potential living donor as patient. Am J Transplant. 2010; 10:731-6.
7 Schicktanz, S, Wiesemann C, Wöhlke S (eds). Ethics in transplantation medicine. Goettingen University Press, 2010; 36-37.
8 Ibrahim HN, Foley R, Tan L et al. Long term consequences of kidney donation. New Engl J Med, 2009; 360, 459-469.
Conflict of Interest: Dr. Schumann receives administrative support from the Department of Medicine to support work as the medical center's Living Donor Advocacy Team physician
The UTSW DAT Response to the Case of Ms D
Posted on February 5, 2011
Fabrice Jotterand, PhD
UT Southwestern Medical Center,
Conflict of Interest: None Declared
Medical parameters that usually limit an individual's ability to donate a kidney include risk for subsequent renal disease, medical co-morbidities that would prevent surgery, and psychological and psychiatric co-morbidities. For Ms D there are possible medical risks for subsequent kidney disease and the tendency toward increased weight. Remediable factors include decreasing weight, smoking cessation, control of blood pressure, avoidance of medications predisposing to renal injury, and optimizing treatment of medical co-morbidities. For donors who may have associated underlying psychological issues, treatment and stabilization of psychosis and/or depression may be remediable. The informed consent process for donation constitutes the ethical standard fostering the donor's wellbeing. This process ensures the donor's ability to provide authorization with competence, understanding and without coercion. At UT Southwestern Medical Center, a multi-disciplinary donor advocacy team (DAT) evaluates donor case histories independent of the transplant team. To this end the DAT developed an algorithm (Independent Donor Ethical Evaluation Assessment) for an objective case review. The algorithm corresponds to the DAT decision-tree and presents the criteria by which all applications are evaluated. There are four decision options: 1) Denial, 2) Deferral Pending Resolution, 3) Approval with Stipulations, and 4) Approval (with or without Recommendations). After final approval, the DAT recommends a 2 week cooling off period prior to surgery unless stated otherwise by the potential donor.
Based on this algorithm, Ms D does not meet the criteria of denial, as she appears to be capable of informed consent, does not have significant psychiatric symptoms or a disorder that would impair judgment with no apparent evidence of coercion or clear evidence for inappropriate secondary gain. However Ms D does meet the criteria for deferral of donor candidacy pending resolution of her ambivalence through individual counseling as she does appear to have some marked ambivalence about donating, when she states that her future risk of diabetes that may lead to kidney failure, "weighs heavy in my mind." She seems also to be concerned about disfigurement as she queries the possibility to remove the kidney vaginally. Furthermore, her language regarding the kidney donation to her mother such as "So it was just not an option" or "So that left me" constitutes red flags suggesting the perception of indirect coercion as she may feel that her mother has no other options and that she has an obligation to donate. Once the question of her ambivalence is handled properly through counseling she could then be approved, but with the stipulations of further education regarding health risks (diabetes mellitus, high BMI, possible disfigurement, increased risk for nephrosclerosis such as hypertensive and focal segmental sclerosis, see Kopple, 2010) and appropriate remedial health practices, including weight loss and exercise. Finally, she should be strongly counseled regarding cigarette smoking, her need to cease and potential weight gain (Cropsey, et al. 2010).
The UTSW DAT finds that this assessment provides consistency in the ministering of donor advocacy and selection and hopes that it will be useful in the decision for Ms D and her donation.
Devasmita Choudhury MD, UT Southwestern Medical Center & Dallas VA Medical Center Fabrice Jotterand PhD, MA, UT Southwestern Medical Center Gerald Casenave PhD, UT, Southwestern Medical Center Carolyn Smith-Morris, PhD, Southern Methodist University On behalf of the UTSW DAT Committee
References:
Kopple, J.D. (2010). "Obesity and Chronic Kidney Disease". Journal of Renal Nutrition 20(5): S29-S30. Cropsey, K.L. et al. (2010). "The Impact of Quitting Smoking on Weight Among Women Prisoners Participating in a Smoking Cessation Intervention". American Journal of Public Health 100(8):1442-1448.

Conflict of Interest: None declared
Unknown Long-Term Risks for 36-Year-Old Woman Who Hopes to Donate a Kidney to Her Mother
Posted on February 4, 2011
Miriam F. Weiss, M.D, M.A.
Renal Replacement LLC,
Conflict of Interest: None Declared
The practice of living kidney donation raises profound medical, relational and ethical concerns. To achieve fully informed consent, medical caregivers should facilitate a dialogue in which both Ms. D and her mother understand the risks and benefits for the other as well as the self. Current medical consensus supports the safety of live kidney donation. Retrospective studies have not found an increased risk of death when donors are compared to general populations such as NHANES (1, 2). However the small number of donors studied beyond 15 years limits even the best of these studies, and changes in the demographics of current donor populations make it difficult to extrapolate from the experience of past decades. Furthermore, the long-term consequences of uninephrectomy are not known for the increasing numbers of donors with obesity, hypertension and borderline levels of glomerular filtration (3).
Transplant centers commonly accept kidney donors like Ms. D who are overweight or obese (BMI > 30). Ms. D has normal blood pressure and no formal laboratory criteria for metabolic syndrome. Nonetheless, I share Ms. D's concern about her risk for diabetes related to her family history. Her mother's renal function deteriorated rapidly after the diagnosis of diabetes. Kidney donation is temporally associated with the development of de novo insulin resistance (4). If Ms. D is of African American or minority heritage she has a disproportionate risk of accelerated loss of renal function after donation and ESRD (5).
In the absence of disease one kidney is believed to provide sufficient reserve function to prevent renal failure (6). However, both obesity and smoking can cause or contribute to progressive renal disease. At 6.8 years after surgery, 47.2% of obese donors had eGFRs in the NKF CKD Stage 3 range. Hypertension was present in 41.6%, and microalbuminuria had developed in 19.4% (7). Thus we would advise Ms. D to lose weight and permanently stop smoking in order to minimize these potentially remediable risks.
Ronald Herrick was the first kidney donor in 1954. His recipient lived 8 years more. Herrick believed that donating an organ was the right thing to do. He modeled that behavior for over 100,000 living kidney donors in the U.S. (based on numbers recorded starting in 1988.) Herrick died at the age of 79 from complications of cardiovascular disease. In his last years he himself required dialysis for ESRD. His experience supports the concern that the known mortality risks associated with decreased GFR and microalbuminuria apply to living donors as well as those with intrinsic renal disease (8).
The pioneering transplant surgeon Thomas Starzl famously opposed live organ donation for ethical reasons. At a 1978 symposium he was asked if he would choose to give a kidney to a son with ESRD. He replied,"I would give him my heart." (9) Ms. D and her 5 sisters might consider giving their mother a different gift of their hearts: a helping hand to perform home dialysis. This alternative to center dialysis offers patients with ESRD a reduction in cardiovascular risk comparable to transplant (10).
References:
1. Ibrahim HN, Foley R, Tan L, et al. Long-term consequences of kidney donation. N Engl J Med. Jan 29 2009;360(5):459-469. 2. Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long -term survival following live kidney donation. JAMA. Mar 10 2010;303(10):959-966. 3. Young A, Storsley L, Garg AX, et al. Health outcomes for living kidney donors with isolated medical abnormalities: a systematic review. Am J Transplant. Sep 2008;8(9):1878-1890. 4. Shehab-Eldin W, Shoeb S, Khamis S, Salah Y, Shoker A. Susceptibility to insulin resistance after kidney donation: a pilot observational study. Am J Nephrol. 2009;30(4):371-376. 5. Lentine KL, Schnitzler MA, Xiao H, et al. Racial variation in medical outcomes among living kidney donors. N Engl J Med. Aug 19;363(8):724-732. 6. Poggio ED, Braun WE, Davis C. The science of Stewardship: due diligence for kidney donors and kidney function in living kidney donation-- evaluation, determinants, and implications for outcomes. Clin J Am Soc Nephrol. Oct 2009;4(10):1677-1684. 7. Nogueira JM, Weir MR, Jacobs S, et al. A study of renal outcomes in obese living kidney donors. Transplantation. Nov 15 2010;90(9):993-999. 8. Matsushita K, van der Velde M, Astor BC, et al. Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet. Jun 12 2010;375(9731):2073-2081. 9. Surman OS, Cosimi AB, Fukunishi I, et al. Some ethical and psychiatric aspects of right-lobe liver transplantation in the United States and Japan. Psychosomatics. Sep-Oct 2002;43(5):347-353. 10. Pauly RP, Gill JS, Rose CL, et al. Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients. Nephrol Dial Transplant. Sep 2009;24(9):2915-2919.

Abbreviations used: NHANES - National Health Assessment and Nutrition Examination Survey BMI - Body Mass Index eGFR - estimated glomerular filtration rate NKF - National Kidney Foundation CKD - Chronic Kidney Disease ESRD -End Stage Renal Disease

Conflict of Interest: None declared
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