Ethical issues surrounding high-risk kidney recipients/living donor

[okarol]

Ethical issues surrounding high-risk kidney recipients: implications for the living donor

O'Hara, Jerome F Jr
Sep 2007 

Evaulating patients for living kidney donor transplantation involving a recipient with significant medical issues can create an ethical debate about whether to proceed with surgery. Donors must be informed of the surgical risk to proceed with donating a kidney and their decision must be a voluntary one. A detailed informed consent should be obtained from high-risk living kidney donor transplant recipients as well as donors and family members after the high perioperative risk potential has been explained to them. In addition, family members need to be informed of and acknowledge that a living kidney donor transplant recipient with pretransplant extrarenai morbidity has a higher risk of a serious adverse outcome event such as graft failure or recipient death. We review 2 cases involving living kidney donor transplant recipients with significant comorbidity and discuss ethical considerations, donor risk, and the need for an extended informed consent. (Progress in Transplantation. 2007;17:180-182)

Living kidney donor transplantation (LKDT) is more cost-effective than dialysis for treatment of end-stage renal disease (ESRD) and provides improved graft and recipient survival.1 Ethical challenges previously described in LKDT include a cerebral vascular accident donor unable to communicate,2 whether to disclose misattributed paternity during evaluation,3 and appropriate donor or recipient age.4 Two cases are presented involving significant recipient preoperative comorbidity that created an ethical discussion about whether to proceed with LKDT. In this article we discuss ethical considerations, donor risk, and the need for an extended informed consent for the patient pair in LKDT with a high-risk recipient.

Case 1

A 64-year-old man presented for LKDT with a medical history of nephrectomy for renal cell carcinoma, long-standing hypertension (>30 years) resulting in peritoneal dialysis-dependent ESRD for 3 years, type 2 diabetes mellitus, congestive heart failure, 2 triple-vessel coronary artery bypass graft procedures 2 years earlier, Coumadin (warfari sodium) therapy for atrial fibrillation, automatic internal cardiac defibrillator placement for ventricular tachycardia/cardiomegaly, and left ventricular ejection fraction of 15%. The donor was the recipient's healthy daughter who was in her 20s. Cardiac consultation concluded that the recipient was not a candidate for cardiac allograft but optimized for LKDT. Intraoperative management included general anesthesia; an arterial catheter; transesophageal echography; a pulmonary artery catheter; defibrillator pad placement; epinephrine, dobutamine, and phenylephrine infusions; and a plan for postoperative ventilation.

The patient remained intubated and required cardioversion for ventricular tachycardia on the day of surgery following the procedure. The postoperative course was complicated by separate readmissions to the intensive care unit for congestive heart failure and to rule out myocardial infarction. Cy tomegalo virus viremia was also confirmed and treated. The patient was discharged on postoperative day 19 with a serum creatinine level of 3.5 mg/dL (309 µmol/L); at 10 months the level was 3.6 mg/dL (318 µmol/L). The donor, recipient, and family remain satisfied with the decision to proceed with LKDT.

Case 2

A 68-year-old man presented for LKDT with a medical history of right lung transplantation secondary to end-stage chronic airway obstructive disease from 3 years earlier, hemodialysis-dependent ESRD secondary to cyclosporine toxicity, previous heavy tobacco use, insulin-dependent diabetes mellitus, and the need for home oxygen therapy at 2 L/m. Room air arterial oxygen saturation was 95%. The donor was the recipient's healthy niece in her 40s. Intraoperative management included general anesthesia, an arterial catheter, and a central venous catheter.

The patient was extubated in the operating room and did well until postoperative day 4, when he was admitted to the intensive care unit with delirium and pneumonia requiring reintubation. The postoperative course was prolonged mainly because of repeated pulmonary complications and ongoing aggressive pulmonary therapy. He was discharged 6 weeks later with a serum creatinine level of 1.1 mg/dL (97 µmol/L); it was 1.4 mg/dL (124 µmol/L) at 4 months. The patient had multiple readmissions to the hospital mainly for pulmonary complications. He died 5 months after surgery following a tracheostomy secondary to empyema, sepsis, and acute renal failure.

Discussion

We present 2 cases involving significant preoperative extrarenai morbidity in LKDT. In case 1, the patient's prerenal transplant cardiac health was compromised. The patient's discharge creatinine level reflected significant dysfunction of the healthy donor allograft. This dysfunction was likely secondary to a low cardiac output status and kidney size mismatch between a 100-kg male recipient and smaller 60-kg donor. In case 2, pulmonary disease put the patient at significant risk of prolonged postoperative intubation and tracheostomy. This patient ultimately required prolonged hospitalization secondary to the postoperative pulmonary complications. Both patients remained dialysis free after transplantation and beyond the time of hospital discharge from LKDT.

Individuals choose to participate in LKDT for many reasons. In some cases the recipient is not even known to the donor and the overarching reason for donation is altruism. When the recipient is a family member or friend, the desire to improve the well-being ofthat person so personal relationships can continue may also be relevant in the donor's decision to proceed. In all cases of living donation, risks to the donor must be weighed in tandem with the potential perioperative risks and benefits to the recipient.5,6 This risk-benefit analysis is crucial to the ethical decisionmaking process, especially when the potential transplant recipient is considered to be a high-risk candidate. Although behavior contracts are not described in LKDT, in heart transplantation it has been suggested that a high-risk living donor transplant recipient should demonstrate intent to be medically compliant by signing a behavior contract.7

LKDT remains an ethically complex issue for many reasons. Generally, the most significant matter is that of subjecting a healthy donor to surgery for the sole clinical benefit of another person (the kidney recipient). LKDT donors must be informed of a recipient's potential for morbidity and mortality before they consent to undergo an unnecessary individual surgery.5,6 This information is especially important if the LKDT involves an altruistic donor who might not consent if he or she knew his or her kidney was being directed to a high-risk recipient with documented extrarenai morbidity. Living donors may also encounter expenses not covered by the recipient's health insurance as well as lost wages during their recovery process.8

Surgery exposes the donor to multiple risks including bleeding, infection, hemorrhage, bowel obstruction, hernia, and death (0.02%-0.03%).9,10 In a retrospective study of 738 consecutive laparoscopie LKDTs, Jacobs et al11 reported the incidence of open nephrectomy conversion as 1.6%; blood transfusion, 1.2%; major intraoperative complications, 6.8%; major postoperative complications, 17.1%; and initial postoperative donor creatinine levels at 1.5 times the preoperative level. After transplantation, LKDT donors are left with diminished physiologic renal function reserve. Living donor nephrectomy patients maintain stable renal function at 20 years (if normal renal function and no hypertension or proteinuria are present at the time of nephrectomy), but at 20 to 25 years there is an increased risk of hypertension, mild proteinuria, and developing renal insufficiency (serum creatinine level >1.4 mg/dL [124 µmol/L]).5 Goldfarb et al12 reported that donor nephrectomy patients with a mean postoperative follow-up of 25 years had an incidence of hypertension comparable to that expected in matched age comparisons. In a recent meta-analysis (48 studies), Boudville et al13 evaluated 5145 donor nephrectomy patients and concluded that they were at risk of a 5 mm Hg blood pressure increase within 5 to 10 years.

Chronological age does not categorically classify the patient as high risk. Recipients 75 years and older are reported to have substantial life prolongation and excellent graft survival after LKDT.14 A "high-risk" recipient should be defined as an individual with a medical, surgical, and/or psychosocial factor that would elevate his or her transplant morbidity or mortality risk. Kandaswamy et al15 reported that recipients with extrarenai morbidity did benefit from LKDT, but questioned whether the donor risk is justified if the recipient's outcome may be limited.

Currently, no consensus or absolute criteria exist regarding living donors for high-risk kidney transplant recipients. For example, in the United States, a guideline issued by the United Network for Organ Sharing states that LKDT should be given to recipients who do not have "any absolute exclusionary criteria for deceased donor kidney transplantation" at the transplant center at which the surgery is to occur.16 Conversely, the British Transplantation Society does not require that recipients meet eligibility requirements for deceased donor transplantation.17 In Australia and New Zealand, high-risk patients are eligible to receive kidneys from living donors if the recipient's perioperative mortality is expected to be "low" and the postoperative life expectancy is at least 5 years.18

Perhaps only patients listed for deceased donation should be allowed access to living donor organs. However, such a policy could fatally penalize ESRD patients who have the capacity to benefit from kidney transplantation but may not survive a lengthy waiting time for a deceased donor organ, which is currently 5 years and expected to increase.9 Allograft survival in ESRD patients is optimized if kidney transplantation occurs before the patient becomes dialysis dependent and if the transplant is from a living donor.1 Due to improved outcomes, the national shortage of deceased donor allografts, and increased patient education, annual LKDT is expected to continue to increase.

The cases presented here proceeded only after the medical teams involved obtained a detailed informed consent for each donor, recipient, and immediate family member addressing the potential of increased graft dysfunction and recipient perioperative mortality risk. The projected lengthy waiting time for a deceased donor allograft was also a factor in the patients' and families' decision to consent to proceed with LKDT.

Conclusion

Each LKDT pair must be individually evaluated psychologically and optimized medically before they proceed with kidney transplantation. In LKDT, a donor's decision to proceed must be voluntary. The donor must appreciate his or her surgical risk and understand that surgery is for the clinical well-being of the recipient. It is crucial that donors, recipients, and immediate family members are informed of and acknowledge that an LKDT recipient with pretransplant extrarenai morbidity has a higher risk for a serious adverse outcome of graft failure or death. These factors contribute to the final decision of whether to proceed with LKDT.

References

1. US Transplant-Scientific Registry of Transplant Recipients. Arbor Research Collaborative for Health With the University of Michigan, http://www.ustransplant.org/default.aspx. Accessed January 31, 2007.

2. Schlessinger S, Crook ED, Black R, Barber H. Ethical issues in transplantation: living related donation in the setting of severe neurological damage without brain death. Am J Med Sci. 2002;324(4):232-236

3. Soderdahl DW , Rabah D , McCune T , et al . Misattributed paternity in a living related donor: to disclose or not to disclose? Urology. 2004;64(3):19-21.

4. Broyer M, Touraine JL, Hors J. Acceptance principles of living-related donors for kidney transplantation. Transplant Proc. 1996;28(1):424-425.

5. Davis CL. Evaluation of the living kidney donor: current perspectives. Am J Kidney Dis. 2004;43(3):508-530.

6. Nolan MT, Walton-Moss B, Taylor L, Dane K. Living kidney donor decision making: state of the science and directions for future research. Prog Transplant. 2004;14(3):201-209.

7. Cupples SA, Steslow B. Use of behavioral contingency contracting with heart transplant candidates. Prog Transplant. 2001;11(2):137-144.

8. Wolters HH, Heidenreich S, Senninger N. Living donor kidney transplantation: chance for the recipient-financial risk for the donor? Transplant Proc. 2003;35(6):2091-2092.

9. Matas AJ. Transplantation using marginal living donors. Am J Kidney Dis. 2006;47(2):353-355.

10. Matas AJ, Bartlett ST, Leichtman AB, Delmonico FL. Morbidity and mortality after living kidney donation, 1999-2001: survey of United States transplant centers. Am J Transplant. 2003;3(7):830-834.

11. Jacobs SC, Cho E, Foster C, Liao P, Bartlett ST. Laparoscopie donor nephrectomy: the University of Maryland 6-year experience. J Urol. 2004;171(1):47-51.

12. Goldfarb DA, Matin SF, Braun WE, et al. Renal outcome 25 years after donor nephrectomy. J Urol. 2001;166(6):2043-2047.

13. Boudville N, Prasad GV, Knoll G, et al. Meta-analysis: risk for hypertension in living kidney donors. Ann intern Med. 2006;145(3):185-196.

14. Macrae J, Friedman AL, Friedman EA, Eggers P. Live and deceased donor kidney transplantation in patients aged 75 years and older in the United States. Int Urol Nephrol. 2005;37(3):641-648.

15. Kandaswamy R, Kasiske B, Ibrahim H, Matas AJ. Living or deceased donor kidney transplants for candidates with significant extrarenai morbidity. Clin Transplant. 2006;20(3):346-350.

16. Ad Hoc Living Donor Committee: Living Kidney Donor Evaluation Guidelines. United Network for Organ Sharing. http://www.unos.org/ContentDocuments/Living_Kidney_Donor_Evaluation_Guidelines2(1).pdf. Accessed January 31, 2007.

17. A Joint Working Party of the British Transplantation Society and the Renal Association. United Kingdom Guidelines for Living Donor Kidney Transplantation. 2nd ed. British Transplantation Society/The Renal Association, http://www.bts.org.uk/forms/guidelines_complete_oct05.pdf. Accessed January 3, 2007.

18. Transplantation Society of Australia and New Zealand and Australian National Organ Allocation Protocols. General Organ Donor Criteria-Kidney. Australia: Transplantation Society of Australia and New Zealand, Inc. http://www.racp.edu.au/tsanz/oap7c.htm. Accessed January 31, 2007.

Jerome F. O'Hara Jr, MD, Katrina Bramstedt, PHD, Stewart Flechner, MD, David Goldfarb, MD

Cleveland Clinic, Cleveland, Ohio

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