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Offline Clark

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Long-term risks for kidney donors
« on: September 20, 2014, 02:14:20 PM »
http://www.nature.com/ki/journal/v86/n1/full/ki2013460a.html

Long-term risks for kidney donors
Geir Mjøen, Stein Hallan, Anders Hartmann, Aksel Foss, Karsten Midtvedt, Ole Øyen, Anna Reisæter, Per Pfeffer, Trond Jenssen, Torbjørn Leivestad, Pål- Dag Line, Magnus Øvrehus, Dag Olav Dale, Hege Pihlstrøm, Ingar Holme, Friedo W Dekker and Hallvard Holdaas
Kidney International 86, 162-167 (July 2014) | doi:10.1038/ki.2013.460

Abstract
Previous studies have suggested that living kidney donors maintain long-term renal function and experience no increase in cardiovascular or all-cause mortality. However, most analyses have included control groups less healthy than the living donor population and have had relatively short follow-up periods. Here we compared long-term renal function and cardiovascular and all-cause mortality in living kidney donors compared with a control group of individuals who would have been eligible for donation. All-cause mortality, cardiovascular mortality, and end-stage renal disease (ESRD) was identified in 1901 individuals who donated a kidney during 1963 through 2007 with a median follow-up of 15.1 years. A control group of 32,621 potentially eligible kidney donors was selected, with a median follow-up of 24.9 years. Hazard ratio for all-cause death was significantly increased to 1.30 (95% confidence interval 1.11–1.52) for donors compared with controls. There was a significant corresponding increase in cardiovascular death to 1.40 (1.03–1.91), while the risk of ESRD was greatly and significantly increased to 11.38 (4.37–29.6). The overall incidence of ESRD among donors was 302 cases per million and might have been influenced by hereditary factors. Immunological renal disease was the cause of ESRD in the donors. Thus, kidney donors are at increased long-term risk for ESRD, cardiovascular, and all-cause mortality compared with a control group of non-donors who would have been eligible for donation.
Unrelated directed kidney donor in 2003, 500+ time blood & platelet donor and counting!
Rep to the OPTN/UNOS Boards of Directors & Executive, Kidney Transplantation, & Ad Hoc Public Solicitation of Organ Donors Committees 2005-2011

Offline Clark

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Risks to Live Kidney Donors: What to Tell Patients
« Reply #1 on: September 20, 2014, 02:55:35 PM »
http://www.medscape.com/viewarticle/830021

Risks to Live Kidney Donors: What to Tell Patients
Jeffrey S. Berns, MD, Peter P. Reese, MD, MSCE

[video]

New Data on Risks to Kidney Donors

Jeffrey S. Berns, MD: This is Jeffrey Berns, Editor-in-Chief of Medscape Nephrology. Today I am with a colleague from the University of Pennsylvania, Peter Reese, a transplant nephrologist and incoming chair of the Ethics Committee of the United Network for Organ Sharing (UNOS). I asked Dr. Reese to join me today to talk about a couple of articles that were recently published on mortality risk associated with living kidney donors. One was published in Kidney International [1] and the other in JAMA.[2] Approximately 6000 living kidney donor transplants are performed yearly in the United States. This is a critical way of acquiring organs for transplant for people with chronic kidney disease or end-stage renal disease. Could you briefly tell us what the 2 articles found and your thoughts about them?

Peter P. Reese, MD, MSCE: These articles are very important because the process of live kidney donation rests on the assumption that you can subject donors to reasonable risks, and they accept them because they have informed consent based on good information. This information is new and it's better than the information we have had in the past. The study from the United States was led by Segev and colleagues,[2] and it looked at living kidney donors in the United States. The other study looked at the experience in The Netherlands.[1] These studies provided new information about the risk for end-stage renal disease.

Relative Risk for End-Stage Renal Disease

The big picture, before these 2 studies, was that live kidney donors had similar survival as well-matched healthy control individuals. Moreover, live kidney donors on average have excellent quality of life compared with healthy control individuals in the population. We didn't previously have precise information about a live donor's risk of needing dialysis in his or her lifetime. Obviously, that is a big deal; it's a key part of informed consent. The 2 studies converged in their findings on the risk for end-stage renal disease. Both studies found that live kidney donors have an elevated relative risk of requiring dialysis. However, in real terms that patients would relate to, the risk of reaching end-stage renal disease in the donor's lifetime is very low.

The estimate from the Segev study related to donors in the United States was that at 15 years, the estimated risk for end-stage renal disease would be less than 1%. Nonetheless, in relative terms, that is higher than it would have been without donating a kidney. There are a few caveats, however.

Dr. Berns: Of importance, what is the comparison population? Can you compare it with a general population, which may be healthy or less healthy than the donors? How was that figured into the equation?

Dr. Reese: Any study of live kidney donation immediately creates the question of the population with whom you are comparing. Live kidney donors, at least in these 2 countries and many others, are selected very carefully. They are supposed to be in excellent overall health, they are supposed to be able to understand informed consent, and they are supposed to have very good renal function. In both of these studies, it was impressive that they created a comparison group of very healthy citizens of their countries. That allowed us to get a little bit closer to the risks attributed to donation.

It appears that the risk for end-stage renal disease for live kidney donors remains lower than the risk for the average person in the population, but the risks are probably higher than if these very healthy people had never donated a kidney.

The Obese Live Donor

Dr. Berns: In a time when obesity is becoming more prevalent and reducing the pool of living donors, we hate to have a message come from these papers that people shouldn't donate kidneys. What take-away message do you want to convey to people who might be considering donating a kidney?

Dr. Reese: Kidney donors need to appreciate that there is a small increased risk for end-stage renal disease. When, along with their providers, they are thinking about whether to go forward with donation, the potential donor's health risk profile must be very carefully examined to determine the donor's risk for future kidney disease. A major limitation of these 2 studies is that we don't know how many of the donors were obese. Neither group of investigators was able to do a subset analysis. They haven't presented any data focusing on obese donors. In theory, there are higher-risk subgroups whose outcomes we can't talk about in a meaningful way.

When I encounter an obese donor, I approach it very explicitly and say, "I don't know your long-term risks for renal disease." When I make a decision with them about whether they can donate, I need to be convinced, and the potential donor needs to be convinced that the benefit of donating is high.

Imagine that you are a parent who wanted to donate a kidney to your child. The benefit of donating to your child would be large, and the potential harm of not donating would also be large, if your lives are entwined in such a way that the recipient's suffering would be shared by the donor.

Dr. Berns: At the end of the day, it's a matter of assessing risk and benefit -- the risk for end-stage renal disease and death related to transplant. The risk is real but still quite small, and it has to be considered in terms of the other potential benefits and risks.

Dr. Reese: My sense is that thoughtful transplant professionals and nephrologists everywhere are worried when an obese person comes forward to donate. We don't have great information with which to counsel them. I hope we will one day in the future.

Dr. Berns: Thank you. This is Jeffrey Berns, Editor-in-Chief of Medscape Nephrology.

2 comments
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Tram-Anh Doan 12 days ago
Great questions and answers. Thankyou! :-)

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Brenda Mayne Sep 3, 2014
I am a living kidney donor. Three years post-donation my eGFR is 35. What this article assumes is that the donors are carefully screened. I was screened - but my transplant center did not tell me that they were using an expanded criteria - essentially an experimental criteria.  My pre-donation eGFR was only 67 - significantly lower than the reported average post-donation GFR of donors in follow-up studies. I believe this expanded criteria is responsible for this change in the outcome literature. I believe that donors such as myself will have higher rates of ESRD than the population as we age. When I tried to talk to my Transplant Center about my concerns, they told me that my lab tests must be in error. As the trend continued in a negative fashion, they told me that my primary care physician was now responsible for my care. When I questioned the criteria used to approve me and other donors, they told me with great exasperation that other centers used even broader criteria and that they had never had a donor need a transplant. However, they had no data on donors past 2 years.

I believe the only true protection for donors must, like so much patient protection, come from the insurance companies (what irony). I believe the insurer paying for the transplant must provide lifetime insurance for the living donor for any donation-related care. Then and only then will donors have someone looking out for their long term health.
Unrelated directed kidney donor in 2003, 500+ time blood & platelet donor and counting!
Rep to the OPTN/UNOS Boards of Directors & Executive, Kidney Transplantation, & Ad Hoc Public Solicitation of Organ Donors Committees 2005-2011

 

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