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91
Living Donation in the News / Variation in adult living donor liver transplantation in the United States
« Last post by Clark on August 02, 2023, 04:59:30 PM »
https://onlinelibrary.wiley.com/doi/abs/10.1111/ctr.14924?campaign=woletoc

Variation in adult living donor liver transplantation in the United States: Identifying opportunities for increased utilization

Clinical Transplantation Special Issue
Volume37, Issue7
July 2023
Krista L. Lentine, Tomohiro Tanaka, Huiling Xiao, Therese Bittermann, Mary Amanda Dew, Mark A. Schnitzler, Kim M. Olthoff, Jayme E. Locke, Sukru Emre, Heather F. Hunt … See all authors
First published: 02 February 2023 https://doi.org/10.1111/ctr.14924
AnnMarie Liapakis and David A. Axelrod are co-senior authors

Abstract
In the United States, living donor liver transplantation (LDLT) is limited to transplant centers with specific experience. However, the impact of recipient characteristics on procedure selection (LDLT vs. deceased donor liver transplant [DDLT]) within these centers has not been described. Transplant registry data for centers that performed ≥1 LDLT in 2002–2019 were analyzed using hierarchal regression modeling to quantify the impact of patient and center factors on the adjusted odds ratio (aOR) of LDLT (vs DDLT). Among 73,681 adult recipients, only 4% underwent LDLT, varying from <1% to >60% of total liver transplants. After risk adjustment, the likelihood of receiving an LDLT rose by 73% in recent years (aOR 1.73 for 2014-2019 vs. 2002-2007) but remained lower for older adults, men, racial and ethnic minorities, and obese patients. LDLT was less commonly used in patients with hepatocellular carcinoma or alcoholic cirrhosis, and more frequently in those with hepatitis C and with lower severity of illness (Model for End-Stage Liver Disease (MELD) score < 15). Patients with public insurance, lower educational achievement, and residence in the Northwest and Southeast had decreased access. While some differences in access to LDLT reflect clinical factors, further exploration into disparities in LDLT utilization based on center practice and socioeconomic determinants of health is needed.
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Living Donation in the News / Living donor liver transplantation in the United States: The way forward
« Last post by Clark on August 02, 2023, 04:55:57 PM »
https://onlinelibrary.wiley.com/doi/full/10.1111/ctr.15068?campaign=woletoc

Living donor liver transplantation in the United States: The way forward

Clinical Transplantation Special Issue
Volume37, Issue7
July 2023
Helen S. Te, Abhinav Humar
First published: 03 July 2023 https://doi.org/10.1111/ctr.15068

The success of the first living donor liver transplant (LDLT) performed in a child in Brisbane1 followed shortly by a series of twenty successful pediatric cases in Chicago2 opened the door for LDLT to become a viable alternative to deceased donor liver transplantation (DDLT), not just for children but also for adults. In fact, LDLT has catapulted to become the main mode of liver transplantation in Asia3 and the Middle East,4 where religious beliefs, cultural norms, organ shortage, and political factors have limited the availability of deceased donors. Yet, despite a consistent growth of liver transplantation in the United States (US) over the past four decades, LDLT remains only a small fraction (<10%) of annual liver transplant volumes.5
Living donor liver transplantation has similar or superior graft and patient survival rates when compared to DDLT,6, 7 but widespread adoption of this procedure in the US has remained fraught with many challenges, particularly in the adult population. For this reason, the Living Donor Community of Practice, the Liver and Intestinal Community of Practice, and the Psychosocial and Ethics Community of Practice of the American Society of Transplantation collaborated to hold a consensus conference where national and international leaders in the field gathered to share knowledge and experience. The participants were tasked to identify current barriers that limit the use of this procedure and to formulate effective strategies that will improve access to this life-saving option. The results of the collaborative work and consensus conference are summarized in the six articles included in this special issue.
To set the stage, the first paper “Living donor liver transplantation: A multi-disciplinary collaboration towards growth, consensus, and a change in culture” describes the entire collaborative process, including the administration of a survey of liver transplant centers, an analysis of the transplant registry, and the conduct of the consensus conference. It describes the selection of participants, identifies the domains discussed, and outlines the modified Delphi methodology used in arriving at consensus. At the end of the conference, strategies to overcome the existing barriers were offered, built around a core that rests on the need for a cultural change to one that embraces LDLT.8
To prepare for the consensus conference, a survey was administered to liver transplant professionals to solicit individual attitudes as well as perceived facilitators and barriers of LDLT amongst liver transplant centers in the US. The survey results are reported in the paper, “A survey of transplant providers regarding attitudes, barriers, and facilitators to living donor liver transplantation in the United States.” The majority of respondents recognize that LDLT mitigates organ shortage, but the procedure is infrequently offered as the best first option to patients in need of liver transplantation. Centers without LDLT programs identify the lack of surgical expertise and institutional support as barriers to offering LDLT, while centers with LDLT programs identify recipient and donor selection factors as the obstacles.9
In addition to the survey, an analysis of the Scientific Registry of Transplant Recipients (SRTR) database was performed to determine the influence of recipient characteristics on the selection of LDLT versus DDLT in liver transplant centers that performed both procedures. The findings are outlined in the paper, “Variation in adult living donor liver transplantation in the United States: Identifying opportunities for increased utilization.” On the background of a low overall LDLT rate at 4.4%, practices are widely variable amongst the liver transplant centers, with some centers performing one LDLT only and other centers electing LDLT in 60% of their liver transplants. Some recipient characteristics, such as older age, male sex, and obesity, are noted to be associated with lesser likelihood of LDLT. In addition, racial and ethnic minorities, public health insurance, lower educational achievement, and Northwest and Southeast residence are also associated with less access to LDLT. The authors call attention to the need for further investigation into the social determinants that contribute to disparity in access to LDLT and for further outreach to foster LDLT amongst these populations so as to promote fair access to LDLT.10
During the conference, participants explored barriers encountered in the engagement of institutional stakeholders in LDLT and in the donor and recipient selection process. The discussions are recapped in the paper, “Living donor liver transplant candidate and donor selection and engagement: Meeting report from the living donor liver transplant consensus conference.” Education to counter insufficient awareness and reinforcement of engagement amongst patients, providers, and institutions are advocated. Moreover, future research to fill in data gaps and to standardize donor and candidate selection and additional resources to support the post-donation management of living donors are also recommended.11
Despite technical advances in LDLT that have led to excellent outcomes, at least half of potential living liver donors are still declined for various reasons, mostly medical or technical. In the paper, “Advances and innovations in living donor liver transplant techniques, matching and surgical training: Meeting report from the living donor liver transplant consensus conference,” the authors pinpoint the most pressing medical barriers to LDLT utilization, which included surgical techniques and donor and recipient matching. The development of robust training pathways that provide more exposure to LDLT is projected to increase the number of proficient LDLT surgeons across the country. Furthermore, utilization of emerging data to better guide recipient and donor selection and creation of a formal liver paired exchange program are expected to mitigate donor-recipient mismatches, as has been accomplished in the living donor kidney transplantation community.12
While LDLT undoubtedly benefits the recipient, it subjects the healthy donor to a high-risk procedure that carries a .4% mortality rate and ∼40% complication rate13 with no direct medical gains to the donor. Most donors do derive improved self-esteem, psychological growth, and improved relationships from the donation process, but many also sustain physical issues and financial difficulties.14 In the paper, “Financial, policy, and ethical barriers to the expansion of living donor liver transplant in the United States: Meeting report from the living donor liver transplant consensus conference,” the authors examine the roles of financial strains, regulatory and oversight policies, and ethical controversies in the growth of LDLT in the US. Proposed strategies to overcome the challenges include the expansion of financial resources and public policy changes that promote financial neutrality for donors, optimization of the informed consent process, and further research into long-term physical and mental outcomes of non-directed living liver donors.15
Living donor liver transplantation is a valuable option for patients in need of a liver transplant. However, barriers related to medical, ethical, financial, and psychosocial factors impede its widespread adoption in the US. The papers in this issue specifically address these barriers with workable interventions through education, policy changes, enhanced infrastructure and resources, and research to provide better guidance to center practices. These interventions are crucial for improving access to LDLT and maximizing its potential benefits. Specifically, the LDLT focus needs to shift from “awareness of its existence” to “full acknowledgment and acceptance of its benefit” at multiple levels, including the community, policymakers, healthcare institutions, transplant teams, other medical providers, transplant candidates, and potential donors. In essence, the dictum that needs to be practiced from here onward is, “LDLT is the best option.”8
93
Living Donation in the News / Illegal organ trade is more sophisticated than one might think -
« Last post by Clark on July 24, 2023, 07:43:12 PM »
https://theconversation.com/illegal-organ-trade-is-more-sophisticated-than-one-might-think-whos-behind-it-and-how-it-could-be-controlled-207446

Illegal organ trade is more sophisticated than one might think - who’s behind it and how it could be controlled

Frederike Ambagtsheer
Assistant Professor (Internal Medicine, Kidney Transplantation & Nephrology), Erasmus University Medical Center

Every now and then the trade in human organs makes national, even international, news.
In March 2023, a Nigerian politician, his wife and a medical middleman were found guilty of an organ-trafficking plot after they brought a man to the UK from Lagos to sell his kidney. Several months later in Kenya, following the arrest of a televangelist on charges of a mass killing of his followers, autopsies on the corpses revealed missing organs, raising suspicions of forced organ harvesting. And, in 2020, researcher Sean Columb exposed how numerous African migrants sold their kidneys in Cairo, Egypt, in hopes of using the earnings to pay smugglers to take them across the Mediterranean into Europe.
These reports and cases are part of a global proliferation of the organ trade that started in the late 1980s. It coincided with advancements in transplantation. Until the 1980s, transplantation was regarded as a risky and experimental procedure. Since the introduction of immunosuppressive drugs in the 1980s (which help to prevent the body from rejecting organs), it has become standardised practice. Organ transplants are now conducted in hospitals in more than 90 countries.
Transplantation has however become a victim of its own success, with demand for organs far outpacing supply. Despite strategies to enlarge the donor organ pool, the worldwide organ shortage grows every year.

I am an organ trade and trafficking researcher . I’ve investigated many aspects of the activity including transplant tourism, the buying of organs, experiences of transplant professionals and police and prosecutors working on criminal cases and how trafficking networks operate.
I’ve found that claims are made about the organ trade in the absence of factual data. These have strengthened popular notions of the issue as an underground crime, organised by mafia-like criminals and “rogue” doctors who perform transplants clandestinely.
The reality is starkly different. The nature of the organ trade is far removed from these mythical depictions. In all criminal cases reported to date, illegal transplants took place in medical hospitals and clinics with the involvement of medical staff. Organ trafficking networks are highly organised with close collaborations between the legal “upperworld” (medical doctors, notaries, lawyers) and the criminal “underworld” (recruiters, brokers).
While it’s likely that there are also unreported, hidden cases that do not take place inside medical institutions, the available knowledge indicates that the medical sector is helping to organise and facilitate the trade in human organs.
The organ trade is a complex crime and is fuelled by the high demand for organ transplants and rising global inequalities. The root causes of the trade need to be addressed, and stronger responses (not necessarily laws) are needed to tackle the more organised and exploitative forms of the trade.
What is the trade in human organs?
Organ trade constitutes the sale and purchase of organs for financial or material gain. The World Health Organization (WHO) first prohibited payments for organs in 1987. Many countries subsequently codified the prohibition into their national laws.
Although reliable figures are lacking, the WHO estimated in 2008 that 5% of all transplants performed worldwide were illegal. Living donor kidneys is the most commonly reported form of organ trade.
The WHO has further estimated that the total number of transplants performed worldwide is less than 10% of the global need. Of all organs, kidneys are highest in demand. About 10% of the world’s population suffers from chronic kidney disease. Between two and seven million of these patients are estimated to die every year because they lack access to proper treatment.
Under these circumstances, desperate patients seek illegal ways to obtain organs outside their home countries. The increased value of organs makes them more profitable. This fuels the desire of some people to trade and sell.
Global developments and catastrophes such as the widening gap between the rich and poor, conflicts, famine, climate change and forced migration further increase the risk of organ sale and exploitation among the world’s vulnerable populations.
Addressing a complex crime
How then can responses to the organ trade be improved? A first step would be to reach agreement on what types of organ trade we find condemnable. This requires an understanding of the trade’s complexity.
Some studies demonstrate that the organ trade can constitute serious organised crime. It can involve physical force, even torture, and the execution of prisoners. But these reports don’t describe the organ trade as a whole.
The organ trade involves a variety of practices which range from excessive exploitation (trafficking) to voluntary, mutually agreed benefits (trade).
These varieties warrant different, data-driven responses.
For example, organ sellers are reluctant to report abuses because organ sales are criminalised and sellers will be held liable. Although many can be considered human trafficking victims and be offered protection, this rarely occurs. Law- and policymakers should therefore consider decriminalising organ sales (removing penalties in the law) and offer organ sellers protection, regardless of whether they agree to provide evidence that helps to dismantle criminal networks.
Countries should also allow medical professionals to safely and anonymously report dubious transplant activity. This information can support the police and judiciary to investigate, disrupt and prosecute those who facilitate illegal organ transplants. Portugal and the UK already have successful organ trafficking reporting mechanisms in place.
Finally, a contested example of a possible solution to reduce organ scarcity and avoid black market abuses is to allow payments or other types of rewards for deceased and living organ donation to increase organ donation rates. To test the efficacy and morality of these schemes, strictly controlled experiments would be needed.
Trials on incentivised organ donation schemes have been proposed since the 1990s by transplant professionals, economists, lawyers, ethicists and philosophers who point out that there may be good reasons to allow payments under controlled circumstances.
While such experiments are currently forbidden by law, national surveys have found various degrees of public support for different types of incentives. In the US, for example, a recent study found that 18% of respondents would switch to favouring payments for sufficiently large increases in transplants, provided that recipients didn’t have to pay out of pocket and that allocation of organs would occur based on objective medical criteria. In short, rather than exclusively focusing on stricter laws, a broader range of responses is needed that both address the root causes of the problem and that help to disrupt organ trading networks.
94
Living Donation Forum / Re: Does Low GFR Mean CKD in Living Kidney Donors?
« Last post by Michael on July 21, 2023, 04:58:11 PM »
I would be remiss if I didn't include a link to the classic LDO message thread on this topic started by the incomparable Dr. William Freeman. His first message was posted on March 19, 2011 and it is as relevant today as it was then. (And in some respects speaks to how little progress has been made in 12 years.)

https://livingdonorsonline.org/ldosmf/index.php?topic=141.msg392#msg392

95
Living Donation Forum / Re: Does Low GFR Mean CKD in Living Kidney Donors?
« Last post by Michael on July 21, 2023, 04:50:21 PM »
What Should a Living Kidney Donor Do?

I've seen lots of posts from living donors who were told they have CKD based on the standard GFR chart. It's happened to me. But... I don't think the right response is "you're probably just fine." I think the correct response is "We don't know."

Unfortunately, there aren't standards agreed upon by medical and insurance professionals for evaluating the health of a living donor's remaining kidney, and there are no plans to do so. (I've asked.) So what to do? I think there are three things:

1. Work with your doctor to measure your kidney health year over year to spot any negative trends. Here are specific suggestions, including a worksheet to help with the tracking: PDF version - https://livingdonorsonline.org/worksheets/LivingKidneyDonorHealthTracker.pdf Word version - https://livingdonorsonline.org/worksheets/LivingKidneyDonorHealthTracker.docx


2. Educate your primary care physician. There are peer-evaluated medical papers/commentaries on the topic, a couple of which are posted above.

3. Support legislative protections. Until there are agreed-upon standards for donors, we are at risk of being denied insurance coverage or charged higher rates. Thus, we need the Living Donor Protection Act of 2023 to be passed in this Congress. There are several state initiatives, too.
96
Living Donation Forum / Re: How Much Water Should You Drink?
« Last post by Michael on July 20, 2023, 02:11:02 PM »
What is Too Much Water Intake?
https://www.webmd.com/diet/what-is-too-much-water-intake

WebMD: "When you drink too much water, you may experience water poisoning, intoxication, or a disruption of brain function."

Symptoms:
  • Your pee is clear.
  • Frequent urination.
  • Drinking water even when you're not thirsty.
  • Nausea or vomiting.
  • Throbbing headaches all through the day.
  • Discoloration of the hands, feet, and lips.
  • Weak muscles that cramp easily.
  • Tiredness or fatigue
97
Living Donation Forum / Re: How Much Water Should You Drink?
« Last post by Michael on July 20, 2023, 01:53:26 PM »
Meaning Behind Color of Your Urine
https://adultpediatricuro.com/meaning-behind-color-of-your-urine/

Occasionally I'll see advice in social media posts to use the color of your urine as a way to determine if you are properly hydrated. Is it legitimate? Several resources online suggest it can be an indicator of overhydration or dehydration. Here is one example: https://adultpediatricuro.com/meaning-behind-color-of-your-urine/

> Clear: you might be drinking too much water.
> Light yellow: your kidneys are functioning properly and you have an appropriate diet.
> Dark yellow to orange: you're dehydrated.

However, the National Kidney Foundation cautions that "The color of your pee can offer clues into your health, but kidney disease typically doesn't show any visible symptoms, so the only way to know if you have it is to get tested." Thus, while urine color can suggest how you're doing with hydration, it is not a measure of whether or not you have kidney disease.
https://www.kidney.org/atoz/content/what-color-your-urine-means
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Living Donation Forum / Re: Does Low GFR Mean CKD in Living Kidney Donors?
« Last post by Michael on July 20, 2023, 11:33:05 AM »
KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5540357/

Kidney Disease: Improving Global Outcomes (KDIGO) is an independent global nonprofit organization that is "developing and implementing evidence-based clinical practice guidelines in kidney disease." KDIGO published clinical guidelines for diagnosing and managing chronic kidney disease (CKD) in 2012. They published guidelines for the evaluation and care of living kidney donors in 2017.

Chapter 19 of the 2017 living donor guidelines provides suggestions for post-donation care. Section 19.3 addresses living kidney donors who are evaluated using the standard measures (from their 2012 guidelines) and determined to have CKD. The recommendation is to treat the donor as any other patient diagnosed with CKD: "Donors should be monitored for CKD, and those meeting criteria for CKD should be managed according to the 2012 KDIGO CKD Guideline." In other words, KDIGO does not recommend treating living donors differently from people with two kidneys when evaluating and diagnosing CKD.
99
Living Donation Forum / Re: Does Low GFR Mean CKD in Living Kidney Donors?
« Last post by Michael on July 19, 2023, 03:59:58 PM »
The Unjustified Classification of Kidney Donors as Patients with CKD
https://journals.lww.com/cjasn/pages/articleviewer.aspx?year=2013&issue=08000&article=00019&type=Fulltext#

This articles analyzes several studies of living kidney donors, GFR, and chronic disease that "provides evidence that kidney donors, despite having reduced GFR, are not at increased risk for CKD-associated morbidity and mortality." More specifically, they conclude "kidney donors with low GFR and no other signs of kidney disease should not be classified as having CKD."

This is good news in the sense that a low GFR on its own does not appear to be associated with higher mortality or progression to End Stage Renal Disease (ESRD). But... it leaves open the question of whether there is reason to be concerned if a living kidney donor has BOTH a low GFR and some other sign of kidney disease such as a high level of albuminuria.

The study doesn't come out and say this directly but you could draw these kinds of conclusions:
  • Low GFR only (no other signs of kidney disease), you're probably OK.
  • Low GFR AND other signs of kidney disease for more than three months, you might have chronic kidney disease.

100
Living Donation Forum / Re: Does Low GFR Mean CKD in Living Kidney Donors?
« Last post by Michael on July 19, 2023, 03:27:55 PM »
Low GFR After Kidney Donation is Not Chronic Kidney Disease
https://atcmeetingabstracts.com/abstract/low-gfr-after-kidney-donation-is-not-chronic-kidney-disease/

Only an abstract of this study is available. They followed a fairly small group of living kidney donors and non-donor patients with chronic kidney disease. They measured kidney health using GFR at the start of the project and again about five years later. The GFR improved for donors and worsened for non-donor CKD patients. They concluded  that "former kidney donors show a substantially different course in kidney function than CKD patients. Even though many kidney donors have a low GFR early post-donation, these healthy individuals should not be regarded as CKD patients. CKD criteria are not suitable for former kidney donors."

(Personally, I would like to see a study with a larger number of participants and a longer period over which the GFRs of donors and non-donors are compared.)
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