Transplant Unit

The following paper was written by Yolande Blance, Staff Nurse at the High Dependency Unit, Ward C9 as part of an advanced nursing course.

Introduction

Kidney transplantation first took place in 1951 and since has become a well known treatment for people with end-stage kidney disease (ESKD) (Hilton and Starzomski 1994; Russell and Jacob 1993). This treatment offers the person with ESKD the chance of full recovery, giving them the opportunity to re-instate their mental and physical abilities, thus improving their quality of life (Hilton and Starzomski 1994).

Since the pioneering days of kidney transplantation there have been major improvements in the success of the treatment. These have been achieved because of better understanding of the immune system, and the discovery of antigen definition and histocompatibility (HLA) in the 1960's.  The immunosuppressant cyclosporin which gave rise to increased success rates and opened the transplant door for many ESKD patients was introduced by Professor Sir Roy Calne at Addenbrooke's in 1978..

Nevertheless, there are problems in kidney transplantation today. This is mostly due to a shortage of available organs required to meet the ever growing number of patients awaiting a transplant. A transplant update by the United Kingdom Transplant Support Service Authority (UKTSSA) of patients on the waiting list, showed an increase from 4425 in 1997 to 4588 in 1998. There was also a corresponding drop in the number of cadaveric donor transplants, from 1138 to 996 within the same period (UKTSSA 1998).

There are a number of reasons for the shortage of organs. There has been a fall in the number of fatalities from road traffic accidents due to seat-belt legislation, drink driving regulations, and other road safety initiatives. Reported is a fall in the number of deaths from intracranial haemorrhage, due to improvements in treatment of such patients (Jakobsen,1995), but this is contradicted by a report from the UKTSSA (1995), which shows there has been an increase in intracranial haemorrhage deaths. Other factors include the patients on the waiting list are getting older, and patients are also being retransplanted.

Due to organ shortage many transplant centres are now looking at ways of increasing the number of organs available for transplantation. For the purpose of this assignment it has been chosen to look at live donation in relation to kidney transplantation. As a background to this study the alternative options of obtaining organs for donation must be considered.

In some countries there is an 'opting out' method, where the person automatically at death becomes a donor unless they have registered not to. In the UK an 'opt in' system is used (Kokkedee 1992). In Leicester there is a non-heart beating donor programme. In Japan where brain stem death is not accepted this method is also used (Nicholson 1996). Xenotransplantation is at the moment a much researched field. There is however much debate, ethically, legally and clinically. At the moment therefore it has not been legalised, and is not an option for organ availability (Klotzko 1998). Other sources include, the cloning of organs, and the moulding of organs. There has also been some discussion in terms of financial reward for donor families, in order to better utilise the number of potential cadaver donors (McNatt 1992). There is also need to improve public awareness about organ donation.

This leaves us with the option of live kidney donation as a potential organ source. It has been chosen to discuss this topic to heighten the author's awareness and equip her with the essential knowledge required to look after patients who undergo such a procedure. This assignment will continue by discussing the advantages and disadvantages, ethically, legally and clinically, of living-related (LR) and living un-related (LUR) kidney donation. It will also cover the psychological implications for the donor, recipient and the family.

History and Background

Live kidney donation falls into two categories. Firstly, there is LR donation where the donor is genetically related to the recipient, for example, sister, father, grandmother, uncle. Secondly, there is LUR donation where the donor is emotionally, as opposed to genetically related in some way, for example, wife, step-mother, in-laws or close friend. However, in LUR donation the donor can sometimes be a stranger.

The first successful LR kidney transplant took place in December 1954 between identical twins. In the 1960's and 70's LR kidney donation was widely utilised because graft survival from this source was much better than that of the cadaveric kidney transplants. However, the 1980's saw the introduction of improved immunosuppressive therapies which narrowed the gap considerably, making transplantation more widely available to the ESKD patient (Bertram et al, 1995).

LUR donation was used in the beginnings of kidney transplantation, but was almost phased out for a number of reasons. Initially there were quite poor results with this method, and together with concern over motivation of the donor, became a rather unconventional treatment of choice. At that point dialysis was increasingly available as an alternative method to maintain a reasonable life for the ESKD patient. It was another means to disfavour the LUR transplant (Spital 1994). Today there is still much controversy over LUR donation but as transplant centres become more desperate in the search for organs, LUR donation becomes more appealing (Ploeg et al, 1993).

At present most kidney transplants which take place are from cadaver donors (figures as seen in introduction), but live donor transplants are on the increase. A report from the UKTSSA showed a 30% increase from 121 live donor transplants in 1997 to 181 in 1998 (UKTSSA 1998). Reports do show survival rates are better than for cadaveric transplants, especially in the LR group (Bertram et al 1995). These results, and reports demonstrating the minimal risks to the donor, have encouraged many transplant centres to reconsider the use of live donors as these procedures become more ethically acceptable (Spital 1994).

Ethical and Legal Issues

There are many ethical questions raised regarding live organ donation. Often heard is the issue of morality and, is it right to remove a perfectly healthy organ from one person and give it to another? Surrounding this are the issues of 'non-maleficence' (doing no harm) for the donor, and 'beneficence' (doing good) for the recipient. There are often differing opinions as to whether the benefits outweigh the risks (Bertram et al 1995), and many surgeons with opposing opinions do not accept the idea, and believe there are enough cadaver donors to supply the waiting list (Isoniemi 1997).

Spital (1994) found in a study of American transplant centres that nearly all used LR donation, and that a high percentage were willing to accept the use of LUR donation, despite previous oppositions and concerns. He also found that most centres only accepted LUR donation when there was emotional attachment, for example spouse or close friend, and that only 15% would consider the use of altruistic donors.

Altruism is considered an activity which living donation relies heavily upon, but often heard are concerns regarding the motivation of the donor. LUR donation as mentioned is usually only considered in the emotional sense, but Evans(1989) argues that true altruism can only occur when there are no emotional relationships or personal involvement with the recipient, and that we must consider this an act worthy of high respect.

Many people are concerned with the possible coercion or pressure which may be put onto donors by families, recipients, or potentially, from transplant teams. They are worried with the severe shortage of organs, that these donors may be too enthusiastically sought, and therefore abused in that sense (Russell and Jacob 1993).

Perhaps the most worrying and controversial issue surrounding live organ donation is the sale of organs, and indeed their commercialisation, especially in the LUR group. In eastern countries it is not uncommon for people to give their organs in return for money, often with no real understanding of the operation involved. This leads to the problems of vulnerability and exploitation often noted. It is also not uncommon for western citizens to travel abroad and buy an organ, have it transplanted, and return to their country for continuation of treatment. This type of organ purgery is frequently refered to as 'Trafficking' (Evans 1989). Questions arising from this are ones of justice and fairness. It also brings concern of possible cross infection of many diseases, because the procedures followed may not be governed or regulated in any way.

The World Health Organisation (WHO) (1991) says that a "Rational argument can be made to the effect that shortage has led to the rise of commercial traffic in human organs, particularly from donors who are unrelated to recipients...". Bartucci (1990), also argues that with the current organ shortage who are we to deny patients the option of buying organs?.

An occurrence in Britain of the trafficking of organs by a surgeon, led to the formation of the Human Organ Transplants Act 1989. This clearly states that organs cannot be exchanged for money.

The Act also stipulates that the removal of an organ from a living person is an offence unless the person whom the organ is for, is proven genetically related. There are strict regulations for the LUR donation procedure, which can be authorised by the Unrelated Live Transplant Regulatory Authority (ULTRA). However in both cases there are criteria which must be met. These include ensuring, no payment or coercion is taking place, consent is obtained willingly from the donor, and there is adequate counselling for the donor and also for the recipient.

Frequently discussed in the literature are the financial implications for the donor. As mentioned it is illegal to exchange organs for money. Often not considered is the length of recovery time required for the donor and the potential loss of earnings which he/she may incur. The idea of re-enbursement, or a sort of compensation has been looked at, but met with much disregard by many, as it could be seen as an incentive or coercion for donation (McNatt 1992; Bertram et al 1995). Alternative suggestions have been thought of in terms of medals or prizes in appreciation of the donor's altruism.

Clinical Implications of Live Donation

Following on from some of the associated ethical issues, it is important to look at the potentially harmful and beneficial clinical aspects of live donation.   Live donation is split into 4 groups. Within the LR group there are three types, the HLA-identical group, usually brothers and sisters with the same genetic make-up. The 1-halotype mismatch group which account for the greatest percentage of live donor transplants, these include brother, sister, and mother, and the 2-halotype mismatch group also include sister, brother, and grandmother. Lastly there is the LUR group.

The survival rates are definitely better than those of cadaver transplants. There are however differences within each of the live donor groups. It is estimated that the half-life of an HLA-identical kidney is between 24 and 26 years, and as most patients in this group are around 35 years of age, most will only ever require one transplant in their lifetime. In the 1-halotype group, half life is approximately 11-12 years. Patients in this group tend to be slightly older around 45 years and it is estimated that approximately 50% of patients have a treatment for life. The half life of the 2-halotype and LUR kidney is similar to that of the cadaveric kidney, around 9-10 years, but it is reported that the live donor group experience fewer rejection episodes, need less immunosuppression and have reduced complications from immunusuppression as a result (Bertram et al 1995, and Jakobsen 1995).

Additionally, graft function following live donation is usually much quicker (normally immediate) compared with cadaver kidneys, and fewer problems are experienced with acute tubular necrosis (ATN). This is believed to be associated with shorter delays in transplanting the organ. This is called the cold ischaemic time in which the kidney after removal is perfused to enhance preservation. In live kidney transplantation the organ is transplanted almost immediately limiting the ischaemic time of the kidney, whereas the cadaveric kidney may have a 12-48 hour delay before being transplanted, thus lengthening the ischaemic time and resulting in delayed function of the kidney (Nicholson 1997). A study carried out on cold ischaemia time against graft survival and function showed after 10 years, a shorter ischaemic time of 0-6 hours had approximately 10-15% better graft survival or function than those of up to 36 hours (Offerman 1998).

Most problems encountered with live donation are associated with the donor. Firstly there are the potentially harmful investigative procedures carried out in the assessment phase. The most hazardous being renal angiography, where there is cannulation of the artery and injection of a radio-opaque dye to determine the blood supply to the kidney. Secondly, there are the short term risks of nephrectomy surgery. Suggested in the literature, there is a mortality rate of between 1 in 1600, and 1 in 3000 (Nicholson 1997, and Bertram et al 1995), but this no more than is associated with any anaesthetic. Nicholson (1997), reminds us however that this figure "must be judged in the context of an operation being performed on a healthy individual.". Other associated risks come with most major abdominal surgery and include haemorrhage, chest and wound infection, pneumothorax, prolonged illeus, thrombosis, and most importantly pulmonary embolism, which is the commonest cause of death following nephrectomy (Nicholson 1997).

Long term complications include prolonged wound pain. Initially this is alleviated with the help of opiate analgesia. In Leicester they found epidural analgesia was of significant benefit to patients. In the later stages pain can be persistent and referral to a pain clinic may be necessary, and has been found to be successful (Nicholson 1997). Hypertension is often noted in the literature as a long term complication of kidney donation and carries a risk of about 30%, but it is also noted, that this is no more than in other people of the same age group (Thiel 1997). A five year follow-up study in America of 134 patients found only two people with hypertension, and both were being treated for their symptoms (Melchor et al 1998). Patients are also told of the possibility of developing proteinuria, which is an early sign of kidney disease, however many studies have failed to show any significant increase associated with renal impairment (Thiel 1997, and Melchor et al 1998). In Norway, out of 1,200 patients, only two developed ESKD (Nicholson 1997). It is therefore necessary for long term follow-up of these patients in order to minimise the potential morbidity from associated problems of kidney donation.

In clinical terms, live kidney donation is considered to carry a minimal risk, and with the benefits for the recipient would seem a potentially valuable source for organ retrieval. However, there are still psychological issues to consider.

Psychological Issues

A main concern of live donation is the psychological impact on the people involved. There is the potential for adverse psychological consequences, in relation to who donates, rejection of the organ or even death of the donor or recipient (Russell and Jacob 1993). They also report that family problems and depression are common and these are usually linked with poor post-operative results or rejection in the recipient.

Fox and Swazey (1974) as cited by Russell and Jacob (1993) suggest that some donation problems stem from the idea of "gift exchange", and that in our society gifting is often associated with giving and receiving, or repayment. When there is organ donation this sociocultural norm becomes broken, leaving a certain imbalance in the relationship. There can be a feeling of debt for the recipient, whereas the donor may feel like the creditor. This is often seen in siblings where previous family tensions can repeat, especially when one member is played off against the other, perhaps bringing out anger and jealousy, shame or reconciliation. For twins it can mean coercion from other family members, as no-one is more suited than he/she, thus adding to psychological tensions should anything go wrong. Donation from parent to child however seems to be less of a problem. This "gift exchange" idea fits well into the parent-child relationship as the parent can give without expectation of receiving.

Organ donation can sometimes induce jealousy in the spouse, where the spouse found it difficult to accept when their partner donated to outside the 'nuclear family', and believed that the family was threatened in some way, thus causing many marital problems and even divorce (Russell and Jacob 1993). Thiel (1997) reported that often the spouse is more enthusiastic about donating to a partner than to a sibling, or other relative, as the emotional bond is stronger, both have a lot to gain by having the transplant, and gives both the potential for a better quality of life. He also says there are fewer emotional problems seen in the LUR transplant, as familial problems tend not to interfere. For the stranger there is an increased self esteem for 'doing good' and enhancing anothers quality of life (Bertram et al 1995).

Some problems that arise after transplantation occur when attention shifts from the donor onto the recipient. It is reported as one of the factors contributing to the depression often felt by donors. There are reports of adjustment disorders, and even suicide or attempted suicide following donation (Morris et al 1987). It is said that thorough pre-operative screening is necessary to uncover any psychological problems, but one cannot always be sure how one will react when under such emotional strain as transplantation (Russell and Jacob 1993). Morris et al (1987) found that past psychiatric history did not affect the outcome.

In Morris et al's (1987) study they found that generally donation was a positive act despite some post-transplant negativities, and that a lack of social support and education was more likely to generate psychological problems later. All donors studied said that given the chance, they would donate again.

Conclusion

This essay has attempted to look at and discuss some of the important issues surrounding live kidney donation. It seems that clinically the results are superior in comparison to the cadaver source, and with minimal risks to the donor. Psychologically donors appear to benefit from the 'doing good' and altruistic motives behind donating. However, ethically, there are many issues which come to light and rattle our consciences as to what is right and what is wrong. Living donation is a treatment which many transplant centres are pursuing. As it becomes more practiced, it becomes more well known, thus, refusal of this procedure may lead patients to search elsewhere for this ultimate cure. This could potentially put themselves at great risk, and open the door to 'trafficking'. But if the donor gives a consent which is willing, altruistic, fully informed and educated, then there seems to be no reason to refuse such a successful treatment.

As health care professionals we are faced with two people who have decided to undertake this procedure. It is our duty to make sure that both patients understand the procedure, both pre- and post-operatively. As professionals we become advocates for both patients and must treat them as individuals, offering them the support and care they require, and ultimately, acting in their best interests.

References and bibliography