Consequences of kidney donation by age in Japanese living kidney donors: a single-center study.

BACKGROUND: Elderly living kidney donors (LKDs) are becoming increasingly important in countries with a high prevalence of living-donor kidney transplants and an aging society. This study explored the features of elderly LKDs, focusing on their subsequent outcomes. METHODS: This single-center, retrospective, observational study included eligible LKDs who donated their kidneys between April 2008 and July 2022. LKDs were categorized into an elderly (≥70 years at donation) or a non-elderly group (<70 years). We examined pre-operative characteristics and post-operative outcomes, such as kidney function, complications, development of end-stage kidney disease (ESKD), and mortality. RESULTS: Of the 188 LKDs observed for a median of 5.7 years, 31 were in the elderly group (16.5%) and 157 (83.5%) were in the non-elderly group (mean age 72.5 ± 2.7 and 58.2 ± 7.3 years, respectively). No significant differences were observed in hospital stay length or peri-operative complications between groups. Both groups experienced a similar decline in post-donation estimated glomerular filtration rate (eGFR)-approximately 37%. In the elderly group, four LKDs died, and one progressed to ESKD. In the non-elderly group, two LKDs died, and none progressed to ESKD. The cause of death was not strongly suspected to be associated with the donation. CONCLUSIONS: eGFR was maintained even in elderly LKDs post-donation. Prioritizing LKDs' safety is paramount; however, donations from elderly people would be acceptable, considering their life expectancy. This can expand the pool of living kidney donors and address the growing demand for kidney transplants.

Longitudinal mortality risks and kidney functional outcomes in Japanese living kidney donors.

OBJECTIVES: Previous studies suggested that living kidney donors do not have a higher risk of death or kidney failure than the general population. However, living kidney donor risk is controversial. Furthermore, only a few studies have evaluated long-term kidney function after kidney donation. METHODS: This study evaluated Japanese kidney donor' long-term outcomes, including mortality and kidney function. From 1965 to 2015, 230 donors (76 males, 154 females, and a median age of 54) were enrolled in this study. The median observation period was 11.0 (range, 0.3-41.0) years. RESULTS: In total, 215 donors were still alive, and 15 had died. Causes of death included malignancies, cardiovascular disease, pneumonia, suicide, gastrointestinal bleeding, and kidney failure. Actual donor survival rates at 10, 20, and 30 years were 95.3%, 90.7%, and 80.9%, respectively. These values were comparable to age- and gender-matched expected survival. Long-term kidney function after donation was evaluated in 211 donors with serum creatinine data. Two donors developed kidney failure 24 and 26 years post-donation, respectively. The percentage of donors whose estimated glomerular filtration rate (eGFR) remained ≥45 mL/min/1.73 m2 at 10, 20, and 30 years after donation were 84.2%, 73.0%, and 63.9%, respectively. Survival rates of donors with eGFR <45 mL/min/1.73 m2 were comparable to those in persons with eGFR >45 mL/min/1.73 m2. CONCLUSION: Our findings revealed that kidney donors did not have a higher long-term risk of death than the general population. Although some donors showed decreased kidney function after donation, kidney function did not impact their survival.

New-onset Kidney Biopsy-proven Membranous Nephropathy Induced End-stage Kidney Disease in a Living Donor: A Case Report.

Thirteen years after kidney donation, a 70-year-old man was referred to a nephrologist because of proteinuria. The serum creatinine, albumin, and urinary protein levels were 2.39 mg/dL, 3.0 g/dL, and 6.72 g/gCr, respectively. A kidney biopsy revealed thickening of the glomerular basement membrane with sub-epithelial deposits, suggesting membranous nephropathy. Considering the apparent interstitial fibrosis and diffuse glomerulosclerosis, supportive treatment was chosen. However, 11 months after the kidney biopsy, hemodialysis was required. The present case constitutes an important teaching point, as glomerular disease can occur in living donors and require careful and long-term medical checkup examinations.

Individualized Decision-Making and Outcomes for the 87-Year-Old Living Kidney Donor: A Case Report.

Introduction: Latvia faces a challenging shortage of available kidney donors, leading to a significant mismatch between demand for kidney transplantation and supply. Although older adult donors require a thorough pre-donation workup to rule out significant medical comorbidities, it offers hope for potential kidney transplantation candidates. Case Presentation: This case study presents the unique scenario of an 87-year-old living kidney donor, where individualized decision-making resulted in outstanding outcomes for both the donor and recipient. Conclusions: The initial assessment for donation, which involves renal scintigraphy, serves as a preventive measure. In cases where one of the kidneys exhibits insufficient function, this approach avoids the necessity for further costly tests, thus preserving resources in the healthcare budget. The decision concerning an older donor should undergo thorough discussion by a multidisciplinary team to minimize perioperative and long-term risks. Nonetheless, a thoughtful approach to elderly donors offers a valuable opportunity to expand the living donor pool in the context of the organ shortage problem.

National Attitudes Toward Living Kidney Donation in the United States: Results of a Public Opinion Survey.

Rationale & Objective: Understanding national attitudes about living kidney donation will enable us to identify and address existing disincentives to living kidney donation. We performed a national survey to describe living kidney donation perceptions, perceived factors that affect the willingness to donate, and analyzed differences by demographic subgroups. Study Design: The survey items captured living kidney donation awareness, living kidney donation knowledge, willingness to donate, and barriers and facilitators to living kidney donation. Setting & Population: We surveyed 802 US adults (aged 25-65 years) in June 2021, randomly selected from an online platform with diverse representation. Analytical Approach: We developed summed, scaled indices to assess the association between the living kidney donation knowledge (9 items) and the willingness to donate (8 items) to self-reported demographic characteristics and other variables of interest using analysis of variance. All other associations for categorical questions were calculated using Pearson's χ2 and Fisher exact tests. We inductively evaluated free-text responses to identify additional barriers and facilitators to living kidney donation. Results: Most (86.6%) of the respondents reported that they might or would definitely consider donating a kidney while they were still living. Barriers to living kidney donation included concerns about the risk of the surgery, paying for medical expenses, and potential health effects. Facilitators to living kidney donation included having information on the donation surgery's safety, knowing that the donor would not have to pay for medical expenses related to the donation, and hearing living kidney donation success stories. Awareness of the ability to participate in kidney-paired donation was associated with a higher willingness to donate. Limitations: Potential for selection bias resulting from the use of survey panels and varied incentive amounts, and measurement error related to respondents' attention level. Conclusions: Most people would consider becoming a living kidney donor. Increased rates of living kidney donation may be possible with investment in culturally competent educational interventions that address risks associated with donating, policies that reduce financial disincentives, and communication campaigns that raise awareness of kidney-paired donation and living kidney donation.

Understanding what the general public thinks about living kidney donation will help to develop better education and increase the number of living kidney donors. We surveyed the public to find out: (1) how aware they are about the opportunity to donate a kidney while alive; (2) how much they know about living kidney donation; (3) whether they would be willing to donate; and (4) what would affect their willingness to donate. We found that teaching people about the risks of donating, decreasing costs related to donation, and raising awareness about it could increase the number of people willing to donate.

Prediction of post-donation renal function using machine learning techniques and conventional regression models in living kidney donors.

BACKGROUND: Accurate prediction of renal function following kidney donation and careful selection of living donors are essential for living-kidney donation programs. We aimed to develop a prediction model for post-donation renal function following living kidney donation using machine learning. METHODS: This retrospective cohort study was conducted with 823 living kidney donors between 2009 and 2020. The dataset was randomly split into training (80%) and test sets (20%). The main outcome was the post-donation estimated glomerular filtration rate (eGFR) 12 months after nephrectomy. We compared the performance of machine learning techniques, traditional regression models, and models from previous studies. The best-performing model was selected based on the mean absolute error (MAE) and root mean square error (RMSE). RESULTS: The mean age of the participants was 45.2 ± 12.3 years, and 48.4% were males. The mean pre-donation and post-donation eGFRs were 101.3 ± 13.0 and 68.8 ± 12.7 mL/min/1.73 m2, respectively. The XGBoost model with the eGFR, age, serum creatinine, 24-h urine creatinine, 24-h urine sodium, creatinine clearance, cystatin C, cystatin C-based eGFR, computed tomography volume of the remaining kidney/body weight, normalized GFR of the remaining kidney measured through a diethylenetriaminepentaacetic acid scan, and sex, showed the best performance with a mean absolute error of 6.23 and root mean square error of 8.06. An easy-to-use web application titled Kidney Donation with Nephrologic Intelligence (KDNI) was developed. CONCLUSIONS: The prediction model using XGBoost accurately predicted the post-donation eGFR after living kidney donation. This model can be applied in clinical practice using KDNI, the developed web application.

Analysis of sexual dysfunction development among male and female living kidney donors.

INTRODUCTION: Living kidney donations (LKDs) face a persistent demand for patients with end-stage renal disease, emphasizing the importance of LKDs' growth and success. Although living kidney donors generally exhibit excellent survival rates, little research has explored the development of long-term sexual dysfunction following LKD. OBJECTIVES: This study aimed to analyze differences in 5-year sexual dysfunction outcomes between male and female living kidney donors, utilizing the TriNetX database, a federated network of electronic medical records from multiple U.S. healthcare organizations. METHODS: A propensity score-matched cohort study compared 45-year sexual dysfunction outcomes in adult male and female living kidney donors from December 2013 to December 2022. Cohorts were matched on age; sex; race and ethnicity; diabetes, cardiovascular, genitourinary, and psychiatric comorbidities; lifestyle-related factors; and medications that may impact normal sexual functioning. Primary outcomes included hazard ratio (HR) for decreased libido, sexual dysfunction (composite of male erectile dysfunction, ejaculatory disorders, vaginismus/dyspareunia, infertility, orgasmic disorders, arousal/desire disorders), and sexually transmitted diseases. Secondary outcomes assessed sex counseling and interpersonal relationship issues with spouses or partners. RESULTS: The matched cohorts included 2315 patients each (male, female), and the mean age was 42.3 ± 12.5 years. At 5 years, male donors had a significantly higher HR for sexual dysfunction (HR, 3.768; 95% confidence interval, 1.929-7.358). Erectile dysfunction occurred in 1% of male patients, while vaginismus/dyspareunia affected <1% of female patients. Other sexual disorders, decreased libido, sexually transmitted diseases, and incidences of sexual and interspousal counseling were not significantly different. CONCLUSION: Male living kidney donors faced a higher risk of developing sexual dysfunction 5 years after donation. While LKD remains a safe and viable alternative, clinicians and donors should be mindful of the potential association with sexual dysfunction postdonation. Further research may enhance support for the well-being of living kidney donors.

Follow-up After Donor Nephrectomy in Living Kidney Donors: How to Manage Living Kidney Donors Postoperatively.

BACKGROUND/AIM: This study investigated the follow-up rate of living kidney donors and explored the factors related to continuous follow-up and remnant renal function, enabling the optimal management of living kidney donors. PATIENTS AND METHODS: We retrospectively evaluated 180 living kidney donors who underwent donor nephrectomies at our institute. Clinical information was obtained from medical charts, and remnant renal function was defined as the estimated glomerular filtration rate 12 months after donor nephrectomy. RESULTS: Overall, 6/180 donors (3.3%) were lost to follow-up within a year, and the follow-up rate gradually declined yearly. Independent risk factors for loss to follow-up included a follow-up period <60 months and graft survival of the recipient (p=0.002 and p=0.043, respectively). Recipient survival was correlated with loss to follow-up; however, this was not significant (p=0.051). Regarding remnant renal function, age ≥60 years, preoperative estimated glomerular filtration rate <74 ml/min/1.73 m2, and a Δsingle-kidney estimated glomerular filtration rate <9.3 ml/min/1.73m2 were independent risk factors for poorly preserved remnant renal function (p=0.036, p<0.0001, and p<0.0001, respectively). Using propensity score matching to adjust for preoperative factors, a Δsingle-kidney estimated glomerular filtration rate <9.3 ml/min/1.73 m2 was the only significant postoperative factor for poorly preserved remnant renal function (p=0.023). CONCLUSION: An increased 5-year follow-up rate could lead to an increase in long-term follow-up, and recipient prognosis may be correlated with the living kidney donor follow-up status. Furthermore, Δsingle-kidney estimated glomerular filtration rate was identified as a factor for establishing the optimal precision follow-up management of living kidney donors.

Association between Hemoglobin A1c and Renal Arteriolar Sclerosis in Subjects Presenting without any Apparent Kidney Dysfunction.

AIMS: Diabetic kidney disease is a major vascular complication in patients with diabetes mellitus (DM). However, the association between the hemoglobin (Hb)A1c levels, notably the prediabetic levels, and renal pathological changes remains unclear. We investigated the association between the HbA1c levels and renal arteriolar lesions in subjects without any apparent kidney dysfunction using a living kidney donor cohort. METHODS: Between January 2006 and May 2016, 393 living kidney donors underwent a "zero-time" biopsy at Kyushu University Hospital. The patients were divided into four groups (HbA1c levels ＜5.6%, 5.6%-5.7%, 5.8%-6.4%, and ≥ 6.5%, or diagnosed with DM [DM group]). Renal arteriolar hyalinization and wall thickening were assessed using semi-quantitative grading. We then investigated the association between the HbA1c levels and renal pathological changes. RESULTS: 158 (40.2%) patients had arteriolar hyalinization and 148 (37.6%) showed wall thickening. A significant correlation was observed between the HbA1c levels and wall thickening (p for trend ＜0.001). An elevated HbA1c level was significantly associated with wall thickening according to a multivariable logistic analysis in subjects with HbA1c levels of 5.6%-5.7% and 5.8%-6.4%, and the DM group, compared with those with HbA1c levels of ＜5.6% (odds ratio [OR], 1.91; 95% confidence interval [CI]: [1.03-3.54] for 5.6%-5.7%, OR, 1.96; 95% CI: [1.09-3.53] for 5.8%-6.4%, and OR, 2.86; 95% CI: [0.91-9.01] for the DM group), whereas arteriolar hyalinization did not increase within the nondiabetic HbA1c levels. CONCLUSIONS: Elevated high-normal HbA1c levels are considered to be independent risk factors for arteriolar wall thickening. Subclinical renal arteriolar sclerosis may develop in patients with prediabetic HbA1c levels.

Reclassification of Genetic Testing Results: A Case Report Demonstrating the Need for Structured Re-Evaluation of Genetic Findings.

Rationale: Alport Syndrome (AS) is a progressive genetic condition characterized by chronic kidney disease (CKD), hearing loss, and eye abnormalities. It is caused by mutations in the genes COL4A3, COL4A4, and COL4A5. Heterozygous mutations in COL4A4 and COL4A3 cause autosomal dominant Alport Syndrome (ADAS), and a spectrum of phenotypes ranging from asymptomatic hematuria to CKD, with variable extra-renal features. In the past, heterozygous mutations in these genes were thought to be benign, however recent studies show that about 30% of patients can progress to CKD, and 15% can progress to end stage kidney disease (ESKD). Presenting Concerns: We present a case of a woman who was noted to have microscopic hematuria pre-living kidney donation. Genetic testing revealed a heterozygous variant of uncertain significance (VUS) in the COL4A4 gene. VUSs are medically nonactionable findings and data show that VUSs can be detected in 41% of all patients who undergo clinical genetic testing. VUSs frustrate clinicians and patients alike. Although they cannot be used in medical decision-making, data suggest that reanalysis can result in the reclassification of a VUS over time. Diagnosis: Post-donation, the index patient had a higher than anticipated rise in serum creatinine, raising a concern for possible intrinsic kidney disease. Kidney biopsy was deemed high risk in the setting of a unilateral kidney thereby limiting possible diagnostic intervention to determine the cause of disease. Intervention: Re-evaluation of prior genetic testing results and reassessment of the previously identified VUS in COL4A4 was performed 5-years post-donation. These analyses, along with the addition of new phenotypic data and extended pedigree data, resulted in the reclassification of the previously identified VUS to a likely pathogenic variant. Outcomes: This case demonstrates the importance of structured, periodic re-evaluation of genetic testing results. With the ever-changing landscape of genetics in medicine, the interpretation of a VUS can be dynamic and therefore warrant caution in living kidney donor evaluations. Studies have shown that about 10% of VUSs can be upgraded to a pathogenic classification after an 18- to 36-month interval. Structured re-evaluation of genomic testing results has not yet been integrated into clinical practice and poses a unique challenge in living kidney donation. Novel findings: This case report highlights the variability of the ADAS phenotype caused by pathogenic heterozygous variants in the type 4 collagen genes. It supports the nomenclature change from a benign hematuria phenotype to ADAS, particularly when additional risk factors such as proteinuria, focal segmental glomerulosclerosis or glomerular basement membrane changes on kidney biopsy are present, or as in this case, evidence of disease in other family members.

Justification: Le syndrome d'Alport (SA) est une maladie génétique progressive caractérisée par une insuffisance rénale chronique (IRC), une perte auditive et des anomalies oculaires. La maladie est causée par des mutations dans les gènes COL4A3, COL4A4 et COL4A5. Des mutations hétérozygotes dans les gènes COL4A4 et COL4A3 provoquent le syndrome d'Alport autosomique dominant (SAAD) et un specter de phénotypes allant de l'hématurie asymptomatique à l'IRC, avec des caractéristiques extrarénales variables. Dans le passé, les mutations hétérozygotes de ces gènes étaient considérées comme bénignes, mais des études récentes montrent qu'environ 30 % des patients peuvent progresser vers l'IRC et 15 % vers l'insuffisance rénale terminale (IRT). Présentation du cas: Nous présentons le cas d'une femme chez qui on avait observé une hématurie microscopique avant un don vivant de rein. Les tests génétiques ont révélé un variant hétérozygote de signification incertaine dans le gène COL4A4. Les variants de signification incertaine (VSI) sont des résultats qui ne peuvent être utilisés médicalement et les données montrent qu'ils peuvent être détectés chez 41 % des patients qui subissent des tests génétiques cliniques. Les VSI sont frustrants tant pour les cliniciens que pour les patients. Bien qu'ils ne puissent pas être utilisés dans la prise de décisions médicales, les données suggèrent que leur réanalyse pourrait entraîner leur reclassification au fil du temps. Diagnostic: Après le don, ce cas index a présenté une élévation de la créatinine sérique plus importante que prévu, ce qui a soulevé une préoccupation quant à la présence d'une néphropathie intrinsèque. La biopsie rénale a été jugée à haut risque dans le contexte de rein unilatéral, ce qui a limité la possible intervention diagnostique pour déterminer la cause de la maladie. Intervention: La réévaluation des résultats des tests génétiques antérieurs et du VSI précédemment identifié dans COL4A4 a été réalisée 5 ans après le don. Ces analyses, ainsi que l'ajout de nouvelles données phénotypiques et de données généalogiques étendues, ont abouti à la reclassification du VSI précédemment identifié en variant probablement pathogène. Résultats: Ce cas illustre l'importance de réévaluer de façon structurée et périodique les résultats des tests génétiques. La génétique étant en constante évolution en médecine, l'interprétation d'un VSI peut être dynamique et, ainsi, justifier la prudence dans les évaluations des donneurs de reins vivants. Des études ont montré qu'environ 10 % des VSI peuvent être reclassés comme pathogènes après 18 à 36 mois. La réévaluation structurée des résultats des tests génomiques, qui n'a pas encore été intégrée dans la pratique clinique, pose un défi unique dans le contexte d'un don vivant de reins. Principales observations: Ce rapport de cas met en évidence la variabilité du phénotype du SAAD causé par des variants hétérozygotes pathogènes dans les gènes du collagène de type 4. Il soutient un changement de nomenclature du phénotype d'hématurie bénigne en SAAD, en particulier en présence de facteurs de risque supplémentaires tels que la protéinurie et la glomérulosclérose segmentaire et focale, de modifications de la membrane basale glomérulaire sur la biopsie rénale ou, comme dans ce cas, de preuves de la maladie chez d'autres membres de la famille.

Argumentación ética en la donación de riñón de donante vivo y sano La autodeterminación, voluntad y generosidad superan los riesgos

el gesto altruista del donante vivo y sano de riñón, relacionado genética o sentimentalmente, se basa en autodeterminación, voluntad y generosidad. La argumentación ética alrededor de la donación de riñón de donante vivo y sano se orienta con las éticas principialista y personalista, la dignidad humana, la corporalidad, la divisibilidad del cuerpo, el mal menor y el mal mayor. Hace parte del derecho a la información amplia y suficiente que recibe el donante sobre los riesgos y posibles complicaciones físicas y morales del procedimiento, por medio del comité de bioética y el grupo de trasplantes. Con base en la argumentación ética planteada se procedió a contestar la pregunta de esta investigación: ¿se debe dejar que una persona viva y sana sea sometida a una cirugía que le dejará mononéfrico de por vida, solo por el deseo de ayudar a otro, a pesar de que existen programas activos con donante cadavérico? El objetivo de este artículo es plantear una argumentación ética sobre la donación de riñón de donante vivo y sano que contribuya a una adecuada orientación de su decisión.

the altruistic gesture of the healthy living kidney donor, genetically or sentimentally related, is based on self-determination, willingness, and generosity. The ethical argumentation around living and healthy kidney donation is guided by principled and personalistic ethics, human dignity, corporeality, divisibility of the body, the lesser evil, and the greater evil. It is part of the right to ample and sufficient information that the donor receives about the procedure's risks and possible physical and moral complications through the bioethics committee and the transplant group. Based on the ethical argumentation raised, we proceeded to answer the question of this research: should a living and healthy person be subjected to a surgery that will leave him/her mononephric for life, just because of the desire to help another, even though there are active programs with a cadaveric donor? This article aims to provide an ethical argumentation on living and healthy donor kidney donation that will contribute to an adequate orientation of their decision.

o gesto altruísta do doador de rim vivo e saudável, relacionado genética ou sentimentalmente, está baseado na autodeterminação, vontade e generosidade. A argumentação ética ao redor da doação de rim de doador vivo e saudável é orientada pelas éticas principialista e personalista, pela dignidade humana, pela corporalidade, pela divisibilidade do corpo, pelo mal menor e pelo mal maior. Faz parte do direito à informação ampla e suficiente que o doador recebe sobre os riscos e possíveis complicações físicas e morais do procedimento, por meio do comitê de bioética e do grupo de transplantes. Com base na argumentação ética proposta, procedeu-se a contestar a seguinte pergunta de pesquisa: deve-se deixar que uma pessoa viva e saudável seja submetida a uma cirurgia que a deixará mononéfrico para sempre, somente pelo desejo de ajudar o outro, apesar de existirem programas ativos com doador cadavérico? Nesse contexto, o objetivo deste artigo é apresentar uma argumentação ética sobre a doação de rim de doador vivo e saudável que contribua para uma adequada orientação de sua decisão.

Why potential donors and recipients not proceed to live kidney transplantation, malatya algorithm / Por qué los donantes y receptores potenciales no proceden al trasplante de riñón vivo, algoritmo de malatya

ABSTRACT Introduction: In some countries, organ donation is not widespread enough due to medical, cultural, ethical and socioeconomic factors. Living-donor kidney transplant constitutes the main source of kidney donation. Aim: To evaluate the causes of cancellation of living-donor kidney transplant and improve the effectiveness of transplant programs. Methods: Medical records of possible donors and recipients who were evaluated for living-donor kidney transplant at a tertiary medical center between November 2010 and September 2019 were reviewed retrospectively. Results: Evaluations were performed on 364 potential donors and 338 living-donor kidney transplant recipients; 207 of the latter (61.24%) underwent living-donor kidney transplant. Immune disorders represented the majority of cancellations (38.84%). Fifty-six donors (15.38%) were rejected mainly due to renal disorders (39%). Conclusion: Timely referral of patients to transplant centers must be guaranteed in order to overcome immune problems. Transplant centers should invest in programs adequate both for their resources and for their patients: paired kidney exchange, desensitization protocols, future research, etc.

RESUMEN Introducción: En algunos países la donación de órganos no es suficiente debido a factores médicos, culturales, éticos y socioeconómicos. El donante vivo de riñón constituye la principal fuente de donación de riñones. Objetivo: Evaluar las causas de cancelación de los donantes vivos de riñón y mejorar la eficacia de los programas de trasplante. Material y métodos: Se evaluaron retrospectivamente los registros médicos de posibles donantes y receptores para trasplante de riñón con donante vivo en un centro terciario, entre noviembre de 2010 y septiembre de 2019​​. Resultados: Se evaluaron 364 donantes potenciales y 338 receptores de trasplante de riñón con donante vivo; 207 receptores (61,24%) se sometieron a trasplante de riñón con donante vivo. Los problemas inmunológicos ocasionaron la mayoría de las cancelaciones (38,84%). A cincuenta y seis donantes (15,38%) se les negó la donación, principalmente debido a problemas renales (39%). Conclusión: La derivación oportuna de los pacientes a los centros de trasplante debe garantizarse para superar las barreras inmunológicas. Los centros de trasplante deberían invertir en programas adecuados, tanto por sus recursos como por los pacientes: protocolos de desensibilización, trasplante renal cruzado, investigación futura, etc.