Fig. 10.1
Donor A and donor B are both blood type incompatible with their intended recipients. They are blood type compatible with the other’s recipient. In a KPD program, donor A can donate a kidney to recipient B in exchange for donor B donating their kidney to recipient A
An altruistic donor’s kidney can start a sequence of transplants between incompatible donor/recipient pairs. For example, the altruist donates a kidney to recipient A, donor A donates to recipient B, donor B donates to recipient C, donor C donates to recipient D, and so on until the chain reaches its conclusion (Fig. 10.2). The number of KPD transplants has increased from 2 in 2000 to 429 in 2011 [2]. This growth has occurred despite the barriers of increased logistical challenges for geographically distant donor/recipient pairs, the potential for broken chains caused by donors who back out, and the KPD system being fragmented across multiple programs managed by organizations such as the OPTN, the National Kidney Registry (NKR), and Alliance for Paired Donation (APD). The longest KPD chain to date was a series of 30 living donor kidney transplants , which took place over 4 months involving 17 hospitals across 11 states and was organized by the NKR [3, 4].
Fig. 10.2
In this example, living donors A–D are incompatible with their intended recipients. An altruistic donor is the catalyst in creating a chain of compatible transplants. The final recipient may be another recipient with an incompatible donor or a recipient listed on the deceased donor wait list
Despite the increased numbers of altruistic and KPD donors , the total number of living donors has decreased by 13.9 % from a high of 6,991 in 2004 to 6,019 in 2011 [2]. While the exact cause of this decrease is unknown, it may be partly attributable to increasing governmental oversight of living donor outcomes. Increased program accountability for living donor outcomes could result in programs declining more marginal candidates. The ILDA can influence the use of these marginal candidates in two distinct ways. In the short term, they can fulfill one aspect of their role through increased advocacy for the donor’s right to donate, although this may be at the cost of their mandate to promote the donor’s best interests. In the long term, the ILDA can take an active role in monitoring their follow-up to determine if their donation does place them at higher risk for poor outcomes.
What Organs Can a Living Donor Donate?
Living Kidney Donors
Living kidney donors are the most common type of living organ donor and they comprise a significant amount of the kidney transplants performed. Of kidney transplants performed in 2011, 32.7 % came from living donors [2]. This 32.7 % represents 5,768 people stepping forward and voluntarily choosing to have one of their kidneys removed for no personal medical benefit with the intent of improving the recipient’s quality of life. The acceptance of living kidney donation by the transplant community and the public is based on studies that have found that the rate of end-stage renal disease in living kidney donors is equal to or better than the rate found in the general population [5–8].
There has been a steady increase in the number of unrelated living kidney donors over the past 11 years [2]. Graft survival rates for kidney transplants from unrelated living kidney donors have been found to be similar to those from related living donors [8, 9], while both types of living donor kidneys have superior outcomes to kidneys from deceased donors [2]. Living donor kidney graft survival compared to deceased donor graft survival is 96.5 % versus 91.9 % at 1 year, 82.9 % versus 70.6 % at 5 years, and 60.9 % versus 43.4 % at 10 years [10]. The differences in these outcomes are often attributed to the scheduled nature of the procedure resulting in decreased cold ischemic time and the living donor evaluation process screening out marginal donors. For example, a transplant program might accept a 55-year-old deceased donor with a 2-year history of diabetes, but it is unlikely they would accept a living donor with these same attributes.
Despite the decline in living donors, they continue to comprise a significant portion of the number of yearly kidney transplants. New OPTN policy implemented in February 2013 should improve collection of follow-up data for the first 2 years post donation. However, it is important that the transplant community continue to engage in long-term tracking and analysis of kidney donor outcomes as it provides essential information to appropriately educate potential living donors of their risk.
Living Liver Donors
While the total number of liver transplants has increased over the past decade, the number of living liver donors has decreased by 52.9 % to 247 in 2011 [2]. Livers from living donors have higher rates of graft survival compared to livers from deceased donors [2], with rates of 88.7 % versus 85.3 % at 1 year, 75.8 % versus 68.4 % at 5 years, and 59.8 % versus 54.4 % at 10 years [10]. Accounting for only 3.9 % of the liver transplants performed in 2011, it is likely that the decrease in living liver donors over the past decade is the result of donor safety concerns [11].
Living Lung Donors
Lung transplants from living donors have never been widely performed and have become extremely rare in the US since 2005, when the implementation of the lung allocation score (LAS) resulted in a substantial decrease in the waiting time for a deceased lung transplant [2, 12]. The median wait time for a lung transplant in 2004, prior to the implementation of the LAS, was 17.3 months compared to a median wait time of 3.6 months in 2011 [2, 10]. The LAS is designed to provide lungs based on medical urgency, thus providing a transplant quickest to those most in need [13]. It is possible that this quicker access to a deceased donor for those most ill combined with the potential risk to a living donor has contributed to the decreased use of living lung donors in the US. While there have been 143 living lung donors since 1998, there have only been 2 since 2008 [2]. Due to the low number of donors, it is difficult to accurately compare outcomes in graft survival.
Other Living Donors
Although extremely rare, it is possible to donate a portion of your intestine or pancreas. According to OPTN data, there have been 39 living intestine donors and 7 living pancreas donors since 1994 with only 4 intestine donors and 1 pancreas donor since 2008 [1]. Due to the low number of donors, it is difficult to accurately compare outcomes in graft survival.
Factors that Impede Living Donation
Donating to Undocumented Recipients
Substantial financial barriers typically arise when a living donor attempts to donate to a recipient who is undocumented . Medicare will not pay for the undocumented recipient’s transplant surgery and private insurance for the recipient can be difficult to obtain. The impact of these financial barriers can be seen in the experience of Angel, an undocumented immigrant in need of a kidney transplant whose brother was a willing living donor [14]. It was only after 2 years of negotiating costs with their hospital, high-profile national attention, and fund-raising that they were finally able to overcome this barrier and proceed with the transplant [14].
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