Why Altruistic Organ Donations Are Not Meeting Demands.

Solid-organ transplantation remains the optimal therapeutic option for end-stage organ disease. Altruistic donation represents the ultimate sign of generosity and the most important gift of life. Currently, <10% of the global needs for transplant are fulfilled. Organ shortages result from an inability to provide an adequate organ supply to match demands. The recently observed stagnation in living kidney donations in the United States is related to a drop in all types of organ donations from living related donors, which has been paralleled with a steady and continuous increase in all living unrelated donations. Some forms of living unrelated donation represent a financially driven survival system within which wealthy recipients exploit poor donors. Low rates of altruistic donation are related to cultural barriers, religious obstacles, fear, and consequent distrust in the system. The low rate indicates a state of lack of societal solidarity, a consequence of the state of subconsciousness at the individual and collective levels that humanity is living in. Human domestication, the conditioning process that humans go through since birth and the primary facilitator of this subconscious state, is guarded through familial, social, cultural, religious, political, and mass media organizations, which are all under the influence of the monetary establishment. Acquired beliefs, mainly during the domestication process, influence our perception of the environment, our values, and ultimately our way of life. Unfortunately, this conditioning process is negatively enforced, leading to a stressful state. The powerful subconscious mind places humans in a permanent survival mode, resulting in loss of intelligence, indispensable for well-being and happiness. Altruistic donation requires a close cooperation between all parties involved in the donation process and necessitates a positive reprograming of our subconscious based on sharing, generosity, satisfaction, gratitude, trust, inner peace, and ultimately happiness, well-known constituents of unconditional love, which represents the peak of consciousness.

Organ Donation in Syria.

The first living donor kidney transplant in Syria was performed 44 years ago; by the end of 2022, 6265 renal transplants had been performed in Syria. Kidney, bone marrow, cornea, and stem cells are the only organs or tissues that can be transplanted in Syria. Although 3 heart transplants from deceased donors were performed in the late 1980s, cardiac transplant activities have since discontinued. In 2003, national Syrian legislation was enacted authorizing the use of organs from living unrelated and deceased donors. This important law was preceded by another big stride: the acceptance by the higher Islamic religious authorities in Syria in 2001 of the principle of procurement of organs from deceased donors, provided that consent is given by a first- or second-degree relative. After the law was enacted, kidney transplant rates increased from 7 per million population in 2002 to 17 per million population in 2007. Kidney transplants performed abroad for Syrian patients declined from 25% in 2002 to <2% in 2007. Rates plateaued through 2010, before the political crisis started in 2011. Forty-four years after the first successful kidney transplant in Syria, patients needing an organ transplant rely on living donors only. Moreover, 20 years after the law authorizing use of organs from deceased donors, a program is still not in place in Syria. The war, limited resources, and lack of public awareness about the importance of organ donation and transplant appear to be factors inhibiting initiation of a deceased donor program in Syria. A concerted and ongoing education campaign is needed to increase awareness of organ donation, change negative public attitudes, and gain societal acceptance. Every effort must be made to initiate a deceased donor program to lessen the burden on living donors and to enable national self-sufficiency in organs for transplant.

Expanding the access to kidney transplantation: Strategies for kidney transplant programs.

Kidney transplantation is the most successful kidney replacement therapy available, resulting in improved recipient survival and societal cost savings. Yet, nearly 70 years after the first successful kidney transplant, there are still numerous barriers and untapped opportunities that constrain the access to transplant. The literature describing these barriers is extensive, but the practices and processes to solve them are less clear. Solutions must be multidisciplinary and be the product of strong partnerships among patients, their networks, health care providers, and transplant programs. Transparency in the referral, evaluation, and listing process as well as organ selection are paramount to build such partnerships. Providing early culturally congruent and patient-centered education as well as maximizing the use of local resources to facilitate the transplant work up should be prioritized. Every opportunity to facilitate pre-emptive kidney transplantation and living donation must be taken. Promoting the use of telemedicine and kidney paired donation as standards of care can positively impact the work up completion and maximize the chances of a living donor kidney transplant.

Neighborhood-level social determinants of health measures independently predict receipt of living donor liver transplantation in the United States.

Disparities exist in the access to living donor liver transplantation (LDLT) in the United States. However, the association of neighborhood-level social determinants of health (SDoH) on the receipt of LDLT is not well-established. This was a retrospective cohort study of adult liver transplant recipients between January 1, 2005 and December 31, 2021 at centers performing LDLT using the United Network for Organ Sharing database, which was linked through patients' ZIP code to a set of 24 neighborhood-level SDoH measures from different data sources. Temporal trends and center differences in neighborhood Social Deprivation Index (SDI), a validated scale of socioeconomic deprivation ranging from 0 to 100 (0=least disadvantaged), were assessed by transplant type. Multivariable logistic regression evaluated the association of increasing SDI on receipt of LDLT [vs. deceased donor liver transplantation (DDLT)]. There were 51,721 DDLT and 4026 LDLT recipients at 59 LDLT-performing centers during the study period. Of the 24 neighborhood-level SDoH measures studied, the SDI was most different between the 2 transplant types, with LDLT recipients having lower SDI (ie, less socioeconomic disadvantage) than DDLT recipients (median SDI 37 vs. 47; p < 0.001). The median difference in SDI between the LDLT and DDLT groups significantly decreased from 13 in 2005 to 3 in 2021 ( p = 0.003). In the final model, the SDI quintile was independently associated with transplant type ( p < 0.001) with a threshold SDI of ~40, above which increasing SDI was significantly associated with reduced odds of LDLT (vs. reference SDI 1-20). As a neighborhood-level SDoH measure, SDI is useful for evaluating disparities in the context of LDLT. Center outreach efforts that aim to reduce disparities in LDLT could preferentially target US ZIP codes with SDI > 40.

Deceased Organ Donation in Syria: Challenges and Solutions.

The first living-donor kidney transplant in Syria was performed 41 years ago; by 2019, 5407 renal transplants had been performed there. Three heart transplants from deceased donors were performed in the late 1980s; cardiac transplant activities have since discontinued. In 2003, a new, national Syrian legislation was enacted authorizing the use of organs from living unrelated donors and from deceased donors. This important law was preceded by another big stride in this regard: the acceptance by the higher Islamic religious authorities in Syria in 2001 of the principle of procurement of organs from deceased donors, provided that consent is given by a first- or second-degree relative. After the enactment of this law, kidney transplant rates increased from 7 per million population in 2002 to 17 per million population in 2007. Kidney transplants performed abroad for Syrian patients declined from 25% in 2002 to < 2% in 2007. Kidney transplants continued at comparable rates until 2010, before the beginning of the political crisis in 2011. Four decades after the first successful kidney transplant in Syria, however, patients needing an organ transplant must rely on living donors only. Moreover, 17 years after the law authorizing use of organs from deceased donors, a program is still not in place in Syria, and additional improvement of the legal framework is needed. The war, limited resources, and lack of public awareness about the importance of organ donation and transplant appear to be major factors inhibiting initiation of a deceased-donor program in Syria. A concerted and ongoing education campaign is needed to increase awareness of organ donation, change negative public attitudes, and gain societal acceptance. Every effort must be made to initiate a deceased-donor program to lessen the burden on living donors and to enable national self-sufficiency in organs for transplant.

Willingness of Hemodialysis Patient's Family Members Toward Kidney Donation: A Cross-Sectional Study.

BACKGROUND AND OBJECTIVES: There is a significant shortage of kidneys available for donation. Family members of hemodialysis (HD) patients are experiencing the suffering of their close relatives, which can be a factor toward better acceptance to kidney donation. Knowledge is also an important factor that might affect willingness. In this study, we aimed to estimate the rate of willingness to donate kidneys as live donors (LD) and identify related potential barriers among family members of HD patients. METHODS: This was a cross-sectional observational study involving family members of adult HD patients from King Abdulaziz Medical City and the King Abdullah International Foundation dialysis project in Jeddah, Saudi Arabia. Participants were interviewed through phone calls using a pretested questionnaire. Calculated sample size was 385. RESULTS: A total of 370 family members of HD patients were included. Median age was 37 (interquartile range: 33-44) years and 64% were male. All participants were first-degree relatives to HD Patients. The majority reported willingness to donate kidneys as LD (n = 300, 81%), a proportion 0.81% with 95% confidence interval (CI; 0.77-0.85). Only 42 (11%) graded their knowledge about kidney transplantation as high or very high. On multivariable analysis, less willingness was shown with age >40 years (adjusted odds ratio [AOR] 0.459; 95% CI 0.266-0.792; P = .005), and female gender (AOR 0.496; 95% CI 0.287-0.856; P = .012). CONCLUSION: The majority of family members of HD patients were willing to donate kidneys. The willingness rate was lower among participants 40 years of age and older, as well as among women. The majority of patients graded their knowledge about kidney transplantation as average or lower. Therefore, education targeting of relatives of HD patients may help optimize knowledge and hence improve acceptance of kidney donation.

The need for a living donor wellness program.

PURPOSE OF REVIEW: Living donation has a tremendous impact in bridging the gap between the shortage of organs and the growing list of transplant candidates but remains underutilized as a percentage of total transplants performed. This review focuses on obesity and social determinants of health as potential barriers to the expansion of living kidney donation. RECENT FINDINGS: The growing rate of obesity and associated metabolic syndrome make many potential donors unacceptable as donor candidates because of the future risk for developing chronic health conditions, such as hypertension and diabetes. There is also increasing evidence demonstrating socioeconomic differences and racial disparities potentially limit access to living donation in certain populations. These potentially modifiable factors are not exclusive of each other and together serve as significant contributing factors to lower rates of living donation. SUMMARY: Living donors make sacrifices to provide the gift of life to transplant recipients, despite the potential risks to their own health. Studies describing risk factors to living donation call attention to the overall need for more action to prioritize and promote the health and well being of living donors.

Living Kidney Donor Evaluation.

Long-term safety of living kidney donation (LKD), especially for young donors, has become a real matter of concern in the transplant community and may contribute to creating resistance to LKD. In this context, the criteria that govern living donor donations must live up to very demanding standards as well as adjust to this novel reality. In the first part, we review the existing guidelines published after 2010 and critically examine their recommendations to see how they do not necessarily lead to consistent and universal practices in the choice of specific thresholds for a parameter used to accept or reject a living donor candidate. In the second part, we present the emergence of a new paradigm for LKD developed in the 2017 Kidney Disease: Improving Global Outcomes guidelines with the introduction of an integrative risk-based approach. Finally, we focus on predonation renal function evaluation, a criteria that remain central in the selection process, and discuss several issues surrounding the donor candidate's glomerular filtration rate assessment.

Ways to Overcome Organ Shortage: Increasing Donor Pool by Accepting Suboptimal Kidney Donors.

Many factors affect organ donations worldwide, including religious factors, legislative decisions, economic factors, presence of organ procurement organizations, cultural issues, the presence of commercial transplant, and other unknown factors. The number of patients with end-stage renal disease has increased by 6% worldwide. Even with more transplant procedures, these numbers have not combated the dramatically increased number of patients on wait lists. With regard to potential living donors, around 50% are either blood group or HLA incompatible with the recipient, which then requires patient desensitization or paired kidney donation or a combination of both. Survival rates of kidney donors and the general population are almost the same 35 to 40 years after donation. Although the renal consequences of diabetes after kidney donation are almost the same as that shown in the general population, other risk factors should be considered, such as hypertension, proteinuria, and low glomerular filtration rate, before donation. It is so far unknown whether donors with impaired glucose tolerance can safely donate. With diabetes, what was considered normal blood sugar in 1960 to 1990 is now considered frank diabetes. What was considered normal blood pressure is now considered hypertension. Because individuals with these parameters were accepted as organ donors in the past and have been shown to maintain good health, it is worth considering the safe use of organs from donors with early diabetes and hypertension. Whereas young donors may have not reached the age at which hypertension, diabetes, and other kidney diseases develop, older donors have the lowest likelihood of developing end-stage renal disease after donation. As a general approach, young donors can be accepted if they have high glomerular filtration rate, but young donors from certain ethnic minorities and/or extensive family history of chronic kidney disease and those less than 18 years old should not be considered.

How Did the War Affect Organ Transplantation in Syria?

Since 2011, the Syrian conflict has destroyed much of the country's infrastructure. The deteriorating humanitarian situation has involved health workers and facilities. In 2010, before the war, 385 kidney transplants were performed in Syria. This number declined to 154 in 2013 (60% less) before increasing to 251 transplants in 2018, which is still 35% less than the number of transplants performed before the war. In addition, the number of operational kidney transplant centers has decreased from 8 in 2010, distributed over 3 cities, to only 4 in 2013, all located in Damascus, which increased to 6 centers in 2019. Interestingly, with regard to type of living donor, the percentage of unrelated kidney donors has decreased by 20% for unclear reasons. Another alarming statistic is that more than 50% of kidney transplant physicians and surgeons are no longer practicing transplant medicine in their centers, either because they have left the country or because their centers had become nonoperational. Since the war, free and timely provision of immunosuppressive drugs for all patients in all provinces has been a leading challenge for health authorities and transplant patients. This difficulty has led to adverse medical consequences for patients. A project to initiate liver transplant came to a halt because of complex reasons but mainly because foreign trainers could not visit Syria. Although the autologous bone marrow transplant program had slowed until recently, it has become more active, involving both autologous and allogeneic transplants. The deceased-donor program is still not available in Syria; the war has just reinforced the many reasons that prevented the start of this program before the conflict. The commitment of transplant teams despite these large challenges continues to be extraordinary. The Syrian conflict has affected all aspects of organ transplant, paralyzing new projects and negatively affecting existing programs.

Cost-effectiveness of four living-donor nephrectomy techniques from a hospital perspective.

BACKGROUND: In Europe, transplantation centres use different nephrectomy techniques: open surgery, and standard, hand-assisted and robot-assisted laparoscopies. Few studies have analysed the disparity in costs and clinical outcomes between techniques. Since donors are healthy patients expecting minimum pain and fast recovery, this study aimed to compare the cost-effectiveness of four nephrectomy techniques focusing on early surgical outcomes, an essential in the donation act. METHODS: A micro-costing approach was used to estimate the cost of implementation from a hospital perspective. Estimates took into account sterilization costs for multiple-use equipment, costs for purchasing single-use equipment, staff and analgesics. The study recruited donors in 20 centres in France. Quality of life by EuroQol-5D was assessed preoperatively, and 4 and 90 days post-operatively. Two effectiveness indicators were built: quality-of-life recovery and post-operative pain days averted (PPDA). The study was registered at ClinicalTrials.gov NCT02830568, on 10 June 2010. RESULTS: A total of 264 donors were included; they underwent open surgery (n = 65), and standard (n = 65), hand-assisted (n = 65) and robot-assisted laparoscopies (n = 69). Use of the nephrectomy techniques differed greatly in cost of implementation and immediate post-operative outcomes but not in clinical outcomes at 90 days. At 4 days, hand-assisted laparoscopy provided the lowest cost per quality-of-life recovery unit of effectiveness (%) and PPDA (days) (€2056/40.1%/2.3 days, respectively). Robot-assisted laparoscopy was associated with the best post-operative outcomes but with the highest cost (€3430/59.1%/2.6 days). CONCLUSION: Hand-assisted, standard and robot-assisted laparoscopies are cost-effective techniques compared with open surgery. Hand-assisted surgery is the most cost-effective procedure. Robot-assisted surgery requires more healthcare resource use but enables the best clinical outcome.

Living-unrelated kidney donor transplantation: Legalization in exceptional circumstances?

The prevalence of end-stage renal disease (ESRD) morbidity and mortality is mounting. Kidney transplantation offers a good means of survival and improves longevity of patients with ESRD. However, not everyone is fortunate to benefit from this lifesaving renal replacement therapy due to the lack of available kidneys, one of the many reasons. It eventually expands the number of patients on waiting list of kidney transplantation. At present, deceased and living-related kidney donor transplantation models are widely used, but with limited success to keep up with the pace of burgeoning ESRD. A debate over the legalization of unrelated living kidney donor transplantation has erupted lately. This short review articles focuses on issues surrounding kidney transplantation in Pakistan and draws an informed conclusion regarding pragmatic legalization of unrelated living kidney donor transplantation in exceptional circumstances. Finally, this article also offers a food for thought for countries facing analogous picture in the field of kidney transplantation.

Managing highly sensitized renal transplant candidates in the era of kidney paired donation and the new kidney allocation system: Is there still a role for desensitization?

Kidney paired donation (KPD) and the new kidney allocation system (KAS) in the United States have led to improved transplantation rates for highly sensitized candidates. We aimed to assess the potential need for other approaches to improve the transplantation rate of highly sensitized candidates such as desensitization. Using the UNOS STAR file, we analyzed transplant rates in a prevalent active waiting-list cohort as of June 1, 2016, followed for 1 year. The overall transplantation rate was 18.9% (11 129/58769). However, only 9.7% (213/2204) of candidates with a calculated panel reactive antibody ≥99.9% received a transplant, and highly sensitized candidates were less likely to receive a living donor transplant. Among candidates with a CPRA ≥ 99.5% (ie. 100%), only 2.5% of transplants were from living donors (13 total, 7 from KPD). Nearly 4 years after KAS (6/30/2018), 1791 actively wait-listed candidates had a CPRA of ≥99.9% and 34.6% (620/1791) of these had ≥5 years of waiting time. Thus, despite KPD and KAS, many sensitized candidates have not been transplanted even with prolonged waiting time. We conclude that candidates with a CPRA ≥ 99.9% and sensitized candidates with an incompatible living donor and prolonged waiting time may benefit from desensitization to improve their ability to receive a transplant.

Donation approval among obese living kidney donor candidates: The impact of metabolic syndrome.

BACKGROUND: The scarcity of organs available for transplantation has increased attempts to augment transplantation by utilizing obese living kidney donors. The literature has suggested that these donors have increased risks postdonation. Not surprising, the threshold for living kidney donor approval among obese persons is typically higher and the process more costly. Therefore, a screening tool to predict the likelihood of approval among obese living kidney donor candidates was created. METHODS: A single-center retrospective study was performed among obese (body mass index ≥ 30 kg/m2) living kidney donor candidates evaluated in clinic (January 1, 2012, to December 31, 2017). Approved candidates were compared with those not approved using multivariable logistic regression, and a prediction tool was generated. RESULTS: Among 389 obese living kidney donor candidates, there were no significant differences in sex or race and ethnicity by approval status. However, nonapproved candidates had a higher prevalence of metabolic syndrome. In the prediction model, glucose impairment and hypertension were most predictive of nonapproval. CONCLUSION: Among obese living kidney donor candidates, several metabolic syndrome components were associated with decreased odds of approval. This tool may serve as a useful initial screening for obese living kidney donor candidates, permitting more cost-effective evaluation processes. The tool could also be used to promote expeditious interventions in the preclinical setting, including weight management programs, to improve the likelihood of donation and postdonation outcomes.

Living-Donor Organ Donation: Impact of Expansion of Genetic Relationship.

In Jordan, the history of organ transplantation started in 1972 with a kidney transplant from a deceased donor. At present, Jordan is in a good position with regard to organ transplantation among developing countries. It remains important to follow through with some decisions and enact laws that would increase the percentage of legal organ donations and transplant procedures. This has involved the expansion of relative degree donation. Until 2013, most relative degree donations involved 1st-degree and 2nd-degree relatives. The degree of genetical and legal relatives in living organ donation was then expanded to allow 4th- and 5th-degree relatives. This expansion to a 5th-degree relative came about when it was realized that the percentage of organ transplants in 2nd-degree relatives was high. Therefore, the idea of organ donation in these degrees may be beneficial, as it can lead to significantly higher numbers of organ donations.

Financial compensation for organ donors.

PURPOSE OF REVIEW: With an increasing demand for donor organs, strategies to increase the number of available donor organs have become more focused. Compensating donors for donation is one strategy proposed to increase the availability of organs for transplant. This has been implemented in several systems internationally, but debate continues in the United States with respect to appropriate strategies. The National Organ Transplant Act (NOTA) currently prohibits the transfer of any human organ 'for valuable consideration' for transplantation, but allows for the removal of financial disincentives. RECENT FINDINGS: Several proposals currently exist for compensating patients for living donation. Recent data have focused on studying and creating mechanisms for reimbursement of costs incurred as part of the donation process, which is related to the removal of disincentives to living donation. Others have advocated for the provision of actual incentives to patients for the act of donating, in an attempt to further expand living donation. The current debate focuses on what measures can reasonably be taken to increase donation, and whether additional incentives will encourage more donation or reduce the motivation for altruistic donation. SUMMARY: Currently, the transplant community broadly supports the removal of disincentives for living donors, including reimbursement of expenses for travel, housing and lost wages incurred during evaluation, surgery and after care. Others have advocated for financial incentives to further increase the number of donor organs available for transplant. Although the removal of disincentives is currently allowed under the existing legal structure of NOTA, providing financial incentives for living donation would require further evaluation of the economics, law, ethics and public readiness for a significant policy shift.

GFR Assessment of Living Kidney Donors Candidates.

Living kidney donation provides the best outcomes (survival, cost, and quality of life) of all renal replacement modalities. Living kidney donors, on the other hand, are at the increased risk of end-stage kidney disease (ESKD) after donation compared with healthy nondonors for multiple possible reasons. Extensive predonation screening is required to assess eligibility for donation to avoid the rejection of suitable candidates and minimize acceptance of donors with increased risk of ESKD. The association between the lower predonation glomerular filtration rate (GFR) and increased ESKD risk in donors highlights the relevance of GFR assessment for living kidney donor candidates. However, the method to evaluate GFR is still debated, and the thresholds of acceptable predonation GFR vary across guidelines. All guidelines favor GFR measurement with an exogenous tracer over estimated GFR, but only the British Transplant Society guidelines mandates it. While the Kidney Disease Improving Global Outcomes Group guidelines advocates for age-independent GFR thresholds, most other guidelines propose various age-dependent GFR thresholds with resulting profound differences in assessment of donor suitability between guidelines. Many important questions are not addressed by any guidelines, including the approach to discordant GFR measurement and estimated GFR results, the use of method-specific GFR thresholds and thresholds dependent on comorbidities or race. Further data are required exploring the associations between these variables and the course of postdonation GFR. Last, GFR evaluation studies conducted in approved donors and not in those initially presenting as potential candidates are questionable regarding their suitability for potential donor evaluation.

Attitudes Toward Living Organ Donation and Willingness to Be a Living Organ Donor Among Chinese Citizens in 3 Cities.

OBJECTIVE: The level of awareness of living organ donation demonstrated by citizens may affect the rate of organ transplantation in their area of residence. The objective of this study was to assess the attitudes toward living organ donation and willingness to be a living organ donor among Chinese citizens. METHODS: The study population consisted of 2250 citizens in Beijing, Shanghai, and Wuhan. Data were collected using a questionnaire developed by the researchers based on the existing literature and expert opinions. The questionnaire included questions designed to assess demographics, attitudes, and willingness. The data were analyzed using SPSS 22.0 software. RESULTS: Overall, 2198 citizens completed the questionnaire, of whom 845 (38.4%) supported living organ donation; however, only 213 (9.6%) participants were supportive of their family members donating living organs. A total of 424 (19.3%) citizens were willing to be living organ donors. Of the respondents, 1173 (53.4%) were neutral toward living organ donation and 1463 (66.6%) were undecided about their willingness to donate. In addition, willingness was positively correlated with age, education level, income, marital status, and having descendants (P < .05). Those who had relatives or friends who had undergone organ transplantation were significantly more likely to be donors than those who did not (P < .05). CONCLUSIONS: The results of our study suggest that Chinese citizens lack an understanding of living organ transplantation, indicating that more work needs to be done to inform the public about organ transplantation in China.