Introducing Incentives and Reducing Disincentives in Enhancing Deceased Organ Donation and Transplantation.

Despite the effectiveness of solid organ transplantation, progress to close the gap between donor organs and demand remains slow. An organ shortage increases the waiting time for transplant and involves significant costs including patient morbidity and mortality. Against the background of a low deceased organ donation rate, this article discusses the option of introducing incentives and removing disincentives to deceased organ donation. Perspectives from ethics, general public opinion, and the health care profession are examined to ensure a comprehensive appraisal and illustrate different facets of opinion on this complex area. Special cultural and psychosocial considerations in Asia, including the family based consent model, are discussed.

AcceSS and Equity in Transplantation (ASSET) New Zealand: Protocol for population-wide data linkage platform to investigate equity in access to kidney failure health services in New Zealand.

BACKGROUND: Kidney transplantation is considered the ideal treatment for most people with kidney failure, conferring both survival and quality of life advantages, and is more cost effective than dialysis. Yet, current health systems may serve some people better than others, creating inequities in access to kidney failure treatments and health outcomes. AcceSS and Equity in Transplantation (ASSET) investigators aim to create a linked data platform to facilitate research enquiry into equity of health service delivery for people with kidney failure in New Zealand. METHODS: The New Zealand Ministry of Health will use patients' National Health Index (NHI) numbers to deterministically link individual records held in existing registry and administrative health databases in New Zealand to create the data platform. The initial data linkage will include a study population of incident patients captured in the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), New Zealand Blood Service Database and the Australia and New Zealand Living Kidney Donor Registry (ANZLKD) from 2006 to 2019 and their linked health data. Health data sources will include National Non-Admitted Patient Collection Data, National Minimum Dataset, Cancer Registry, Programme for the Integration of Mental Health Data (PRIMHD), Pharmaceutical Claims Database and Mortality Collection Database. Initial exemplar studies include 1) kidney waitlist dynamics and pathway to transplantation; 2) impact of mental illness on accessing kidney waitlist and transplantation; 3) health service use of living donors following donation. CONCLUSION: The AcceSS and Equity in Transplantation (ASSET) linked data platform will provide opportunity for population-based health services research to examine equity in health care delivery and health outcomes in New Zealand. It also offers potential to inform future service planning by identifying where improvements can be made in the current health system to promote equity in access to health services for those in New Zealand.

Socioeconomic inequality: accessibility and outcomes after renal transplantation in New Zealand.

BACKGROUND: Socioeconomic deprivation (SED) is a risk factor for worse outcomes after renal transplantation (RTx). This study aimed to evaluate access to RTx in different SED strata of the New Zealand population. We also assessed patient survival, acute cellular allograft rejection (AR) and allograft loss. METHODS: This was an Australian and New Zealand Dialysis and Transplantation and Organ Donation Registries-based retrospective cohort study. Patients who underwent RTx in New Zealand from 2008 to 2018 were identified. Patients younger than 16 years of age and those who left the country after RTx were excluded. RESULTS: In the higher SED stratum of New Zealanders, the rate of RTx was 53% greater than in the lower SED stratum (odds ratio = 1.53; 95% confidence interval: 1.33-1.76; p < 0.00005). RESULTS: One hundred and thirteen (23%) patients from the lower SED group and 51 (14.8%) patients from the higher SED group underwent living unrelated RTx, p = 0.0033. In 233 (67.5%) patients from the higher SED group and 265 (53.9%) patients from the lower SED group, transplanted kidneys were from deceased donors RTx, p = 0.0001. The incidence of allograft loss and patient survival were similar in these groups. CONCLUSION: Our data demonstrated a lower overall survival in the more socioeconomically deprived patients than in the lower SED group however this was not statistically significant after adjustment for covariates. A larger study is required to determine whether SED is associated with reduced survival.

ABO blood group incompatible renal transplantation in New Zealand: a report of the first 20 cases.

AIM: To report on the first 20 ABO blood group incompatible (ABOi) renal transplants performed in New Zealand. METHOD: Prospective short-term data and retrospective longer-term follow-up data was collected on the first 20 such transplants between March 2008 and April 2015. RESULTS: Patient and graft survival was excellent at 95% at 12 months and final follow-up (11-85 months; median 31 months). Three serious infections were noted in this time period, one of which resulted in patient death (pneumococcal pneumonia). There were no episodes of anti-ABO blood group antibody mediated rejection. Only one patient was not able to achieve appropriate antibody reduction prior to the planned transplant. CONCLUSION: ABOi transplantation is a safe and successful treatment option for patients with end stage renal failure who cannot access an ABO compatible live donor.

Organ trafficking and transplant tourism: the role of global professional ethical standards-the 2008 Declaration of Istanbul.

By 2005, human organ trafficking, commercialization, and transplant tourism had become a prominent and pervasive influence on transplantation therapy. The most common source of organs was impoverished people in India, Pakistan, Egypt, and the Philippines, deceased organ donors in Colombia, and executed prisoners in China. In response, in May 2008, The Transplantation Society and the International Society of Nephrology developed the Declaration of Istanbul on Organ Trafficking and Transplant Tourism consisting of a preamble, a set of principles, and a series of proposals. Promulgation of the Declaration of Istanbul and the formation of the Declaration of Istanbul Custodian Group to promote and uphold its principles have demonstrated that concerted, strategic, collaborative, and persistent actions by professionals can deliver tangible changes. Over the past 5 years, the Declaration of Istanbul Custodian Group organized and encouraged cooperation among professional bodies and relevant international, regional, and national governmental organizations, which has produced significant progress in combating organ trafficking and transplant tourism around the world. At a fifth anniversary meeting in Qatar in April 2013, the DICG took note of this progress and set forth in a Communiqué a number of specific activities and resolved to further engage groups from many sectors in working toward the Declaration's objectives.

Fatal human herpesvirus-6 infection after renal transplantation.

INTRODUCTION: Human herpesvirus (HHV)-6 infection is common after organ transplantation; however, most cases are associated with a mild clinical course. Donor-derived infection is rare, and there are no reports of HHV-6 infection in more than one recipient from a common donor. METHODS: We describe two patients who developed severe, and in one case fatal, HHV-6 variant A infection after renal transplantation. RESULTS: Both patients presented with severe colitis followed by the development of liver dysfunction and cytopenia. Multiple specimens from both recipients were positive for HHV-6 polymerase chain reaction variant A. Serum and white cells from the donor were positive for HHV-6 DNA, suggesting a donor-derived infection in these patients. CONCLUSIONS: We report two cases of donor-derived HHV-6 infection from the same deceased donor, resulting in a fatal outcome in one patient. Treatment with valganciclovir was successfully instigated in one patient with a full recovery from the infection.

Live donor liver transplantation in New Zealand: a report on the first 20 cases.

BACKGROUND: Liver transplantation (LT) is established treatment for adults and children with acute or chronic liver failure, however there are insufficient donor organs to meet demand and 14% of New Zealand patients have died waiting or were de-listed due to deterioration whilst on the waiting list. Live donor liver transplantation (LDLT) offers an alternative graft source that enables timely transplantation, but also carries the risk of morbidity and mortality for the donor. AIM: To report the initial experience with LDLT in New Zealand. METHODS: Review of donor and recipient outcomes for the first 20 cases. RESULTS: 129 potential live liver donors were assessed for 68 recipients. Donors were evaluated according to a multi-step protocol including independent donor advocacy. Twenty LDLT were performed on 7 adults and 13 paediatric recipients using 5 right lobe, 2 extended left lobe, 2 left lobe, and 11 left lateral section grafts. Five donors (25%) experienced postoperative complications, none of which were life-threatening. Four recipients had acute liver failure and 16 had chronic liver disease including one retransplant. There was a high rate of recipient biliary complications (40%) but graft and recipient survival is 100% to date. CONCLUSION: LDLT has been successfully introduced in New Zealand with good donor and recipient outcomes.

Improving equity of access to deceased donor kidneys in New Zealand.

Before 1999, deceased donor kidneys in New Zealand were allocated by local nephrologists on the basis of local needs and factors thought to be beneficial to graft outcome-in particular, matching tissue type. Waiting times were much longer for patients whose tissue type was different from that of our mainly white population of deceased donors. A National Kidney Allocation System was developed that improved equity of access for our unique population base in New Zealand, taking into account not only tissue-type matching but time spent waiting.

The macrophage is the predominant inflammatory cell in renal allograft intimal arteritis.

BACKGROUND: Intimal arteritis defines acute vascular rejection in the Banff 97 schema. The arteritis is generally considered to be lymphocytic, although the cellular infiltrate in tubulitis is composed of both lymphocytes and macrophages. This study aimed to determine the extent of macrophage involvement in renal allograft intimal arteritis. METHODS: We obtained archival biopsy material from 57 biopsies of 34 renal allografts transplanted between March 1999 and February 2002. All biopsies were diagnostic. We examined clinical and histological parameters. Biopsies were graded using the Banff 97 criteria. We identified macrophages and memory T cells using immunohistochemistry for CD68 and CD45RO, respectively. RESULTS: In all, 24 biopsies showed borderline rejection, and 12 biopsies showed grade IA, 13 showed grade IB, and 8 showed grade II or III acute rejection. Both lymphocytes and macrophages were present in the tubulointerstitium in all grades of acute rejection. We identified intimal arteritis in 10 vessels in eight biopsies. The infiltrating cells invariably included CD68-positive cells; however, we saw intimal CD45RO-positive cells in only seven vessels. There were significantly more CD68-positive cells than CD45RO-positive cells (mean, 9.5 vs. 4.4 positive cells per vessel, P< 0.01). CD45RO cells were never the predominant component of the intimal inflammatory infiltrate. CONCLUSIONS: In the intimal arteritis of biopsies graded as Banff II or III acute rejection, the infiltrating cells were predominantly macrophages. T cells were in the minority. This finding challenges the assumption that the mononuclear cells in intimal arteritis are predominantly lymphocytic.

Subcutaneous black fungus (phaeohyphomycosis) infection in renal transplant recipients:three cases.

We describe three cases of subcutaneous phaeohyphomycosis developing in the lower limbs of renal transplant recipients shortly after transplantation. Each case presented with dark-colored nodules that subsequently ulcerated. Histopathologic examination revealed dematiaceous fungal hyphae with a surrounding granulomatous reaction. The fungi were subsequently identified as Alternaria alternatum in two cases and Phialophora richardsiae in one case. In one case, the lesions resolved during a prolonged (6-month) course of itraconazole without the requirement for surgical excision. In the other two cases, combined medical and surgical treatment resulted in cure. A review of the literature on phaeohyphomycosis is presented.

The Auckland experience with laparoscopic donor nephrectomy.

AIMS: To examine the initial experience of laparoscopic donor nephrectomy (LDN) in New Zealand and compare it with open donor nephrectomy (ODN). METHODS: All LDNs performed between June 2000 and June 2002 were reviewed. An equal number of ODNs were reviewed. Data were also collected on the recipients of the grafts. Key clinical data were prospectively collected; remaining data were collected by retrospectively reviewing patient charts. Auckland Hospital databases were accessed for costing analysis. RESULTS: Thirty five cases of each procedure had been performed. There has been 100% LDN graft survival. There was no significant difference in graft function (serum creatinine) at one and 12 months (p = 0.25 and 0.35) between the two groups. There was no significant difference in donor morbidity (26% vs 31%, p = 0.59). LDN resulted in a shorter hospital stay (3 vs 6.5 days, p <0.0001) and convalescence period (3 vs 6 weeks, p <0.0001). LDN was significantly more expensive (13 357 dollars vs 6713 dollars, p <0.0001). CONCLUSIONS: LDN in the New Zealand setting provides effective grafts for renal transplant recipients and is safe for the donor. Advantages for the donor are a shorter hospital stay and convalescence period. The major disadvantage of LDN is its higher cost compared with ODN.

Calcineurin inhibitor nephrotoxicity: reduction in dose results in marked improvement in renal function in patients with coexisting chronic allograft nephropathy.

BACKGROUND: Calcineurin inhibitors (CNI) have significantly reduced the incidence of acute rejection. Nephrotoxicity however, may contribute to long-term allograft dysfunction. METHODS: Forty-six biopsies from patients who had been transplanted for more than 6 months were examined. Sixteen biopsies had evidence of chronic allograft nephropathy (CAN) alone, 21 biopsies had evidence of coexisting CAN in addition to histological evidence of calcineurin inhibitor nephrotoxicity (CNIN) while nine had neither evidence of nephrotoxicity nor CAN. Patients with evidence of nephrotoxicity underwent a reduction in dose of CNI while those with CAN alone had no change in therapy. Renal function was followed for a mean of 17.4 months after biopsy. RESULTS: The serum creatinine at the time of diagnostic renal biopsy was comparable between those with CAN alone (mean 0.25 +/- 0.18 mmol/L) and those with coexisting CNIN (mean 0.23 +/- 0.05 mmol/L, p=0.33). The patients with CNIN however, had a rapid improvement in renal function within 1 month after dose reduction. This was sustained for the duration of follow-up (mean serum creatinine 0.162 +/- 0.038 mmol/L at 1 yr after dose reduction; p=0.001). In comparison, those with CAN alone had a gradual decline in renal function with a serum creatinine at 1 yr after biopsy of 0.31 +/- 0.187, p=0.01. CONCLUSION: Reduction in the dose of CNI in those with histological evidence of nephrotoxicity resulted in a sustained improvement in renal function.