Topics in Transplantation

Topics in Transplantation

Speakers at a “Controversies in Organ Transplant Policy” session at Renal Week 2010 described a range of issues affecting both kidney donors and recipients.

In recent years, the 60- to 80-year-old age group on the kidney transplant waiting list has increased dramatically, decreasing their chances of ever receiving a kidney. Yet studies show that even those older than 70 can decrease their chance of death and increase the length of their life with a kidney transplant.

Unrelated living donors in the United States have increased to the point where they were the most common category in 2009, most likely because of swaps and chains, said Gabriel Danovitch, medical director for the Kidney and Pancreas Transplant Program at the University of California, Los Angeles.

Three years ago, Garet Hil’s daughter’s kidneys failed, and he and his family entered a desperate race to find a living donor for her, including asking 100 family and friends to be tested and entering into every paired organ exchange program that existed in the United States. After several months of angst, they found that Hil’s 23-year-old nephew was a compatible match.

Kidney transplants are being performed in an era when higher-risk donor organs are being used. One could expect, given this scenario, that posttransplant renal function and graft survival would be adversely affected.

Refreshingly, recent studies show that kidney transplant function in the United States has improved in recent years, as has also graft survival.

The call had come. A donor was identified for 18-year-old Tim. His path to transplantation was not the smoothest, but in many ways, it was perhaps quite typical. He had received a diagnosis of Alport syndrome at a young age. Throughout his adolescence, his engagement was poor. He had received immunosuppressive therapy for a few years, with fluctuant drug levels. He often sat through appointments without his hearing aids and would provide very little independent information.

A wide array of ethical issues comes into play regarding renal transplantation after prior solid organ transplantation. They include concerns about prevention and access. One must first understand the scope of the problem. The prevalence of chronic kidney disease (CKD) among prior non–renal organ transplant (NRTx) recipients is between 80 percent and 100 percent for those who survive three years. The more advanced stages of CKD, types IV and V, occur in 5–20 percent of patients by five years after NRTx, and they vary according to the type of transplant.

Outcomes of kidney transplants and the rate of deterioration in posttransplant kidney function in the United States have improved in recent years. This news provides optimism to patients awaiting transplants, their caregivers, and their families, as well as the assurance that they are waiting for a transplant that has a durable lifespan and function. These gains are particularly tied to advances in patient selection and medical management of the many complexities posed by renal transplantation.