Health Journalism 2008: Current controversies in transplantation

By Sue Pondrom
independent journalist

Wall Street Journal reporter and panel moderator Laura Meckler told attendees at the "Current Controversies in Transplantation" session that "the most interesting thing about the field of transplantation is that unlike most any other field of medicine, we have true rationing. There just aren't enough organs and no matter how much money you have, you can't yet buy one."

Although current U.S. law prohibits it, panelist Scott Halpern, M.D., Ph.D., a bioethicist with the University of Pennsylvania School of Medicine, said paid donation may be a wave of the future. However, there are good reasons to oppose it, he said. Payment might cause some people to overlook the risks associated with live donation. The poor may be exploited, altruistic donation may decline, and society might ostracize paid donors, much as society condemns prostitution.

Touching on another issue in transplantation, Mayo Clinic surgeon Mark Segall, M.D., described a potential new kidney allocation system that more appropriately matches donors and recipients. Currently, kidneys are allocated based on several criteria, with the most weight given to those who have waited the longest. Sometimes this results in a scenario where a "young" kidney from a 19-year-old donor might be transplanted into a 70-year-old recipient, who could die a couple years later with a still functioning kidney.

An alternative approach was studied by a special committee of the United Network for Organ Sharing (UNOS), which has developed an allocation plan based upon a continuous scoring system for candidates, called life years from transplant (LYFT); a continuous scoring system for donor organs, called the donor profile index (DPI); and an opportunity for patients to move up the waiting list over time. LYFT, for example, measures increased life span as a direct result of receiving a kidney transplant versus remaining on dialysis. Under the proposed allocation method, a young kidney would generally go to an age-matched recipient, and an older or less-perfect kidney to an older recipient. Developed over the past four years, the new allocation plan has not yet been adopted.

Another kidney transplant specialist, Johns Hopkins University's Robert Montgomery, M.D., described paired donation, a method of live donation that increases the number of recipients. A new method utilized over the past few years, paired donation involves individuals who wish to give a kidney to their friend or loved one, but cannot because they are incompatible (e.g. wrong blood or tissue type). Now, the donor and recipient are matched with another incompatible couple and the kidneys are exchanged between the pairs. For example, donor A wants to give to recipient A, but is incompatible. Ditto for donor and recipient B. In paired donation, donor A's kidney goes to recipient B (who is a match), and donor B's kidney goes to recipient A. This method can accommodate several potential donors and recipients. Montgomery noted that his team plans to do a six-way paired donation transplantation procedure in the near future.

On another issue involving live donation, Georgetown University surgeon Lynt Johnson, M.D., touched upon guidelines and informed consent. He noted that live liver donations began in 1998 and had reached about 500 a year in the United States by 2001. Following the death of two liver donors that year, the number of live liver donations dropped to about 300 a year – a number that has remained fairly constant. In November 2003, UNOS adopted bylaws requiring live donor liver transplant programs to be certified. Then, in June 2006, the Health Resources and Services Administration (HRSA) required that guidelines be developed for donors of all living organs, including kidney and liver.

As a result, a UNOS living donor committee reviewed all the existing living donor protocols and found a wide variation in living donor evaluation and the consent process. The committee developed a set of voluntary recommendations that included donor evaluation criteria, an informed consent process, and independent donor advocacy. The proposal was released in July 2007 to mixed reaction. Critics felt the proposal was too restrictive, Johnson said.

While the standards for a live donor transplant program have evolved after the two liver deaths in 2001, "a guiding principle to perform a living donor transplant should include the issues of limited alternative donor sources, low morbidity and mortality risk, as well as a good expected outcome in the recipient," Johnson said, adding that voluntary standardized guidelines for evaluation and informed consent are currently in place or are being developed.