Paired kidney donation: are we going beyond reasonable limits in living-donor transplantation?

Abstract

The growing demand for transplant kidneys requires strategies to increase organ supply and avoid long waiting periods on the list. The increase in the number of transplants from living donors involves the growth in the use of unrelated donors and paired kidney donation. Most of these transplants are performed in the USA, where they already represent, respectively, 34% and 16% of total transplants from living donors. In Latin America, and especially in Brazil, there is no collective enthusiasm for these modalities, either at the request of transplanters or that of the community, with the region's priority being to increase transplants from deceased donors, which growth can be up to three-fold. Concerning transplants from matched donors, the possible conflicting results between donors can generate public challenges and they risk compromise the concepts of equal opportunities for transplant candidates, with the possibility of generating resistance to organ donation, especially in regions with socioeconomic limitations and disparities in access to qualified health care and education. This donation model involves challenging ethical and logistical issues, which are subject to questionings, starting with an act of exchange between two pairs until reaching embarrassing proposals, which can compromise the altruistic character of organ donation, and thus not be universally incorporated.

Kidney Paired Exchange: a step too far or a winning hand?

“…They worry that poor outcomes of KPD might adversely affect organ donation. In conclusion, Medina-Pestana et al 5 urge caution in blindly assuming that renal transplantation is superior to dialysis, especially as patients are at risk for immunosuppression and for disease transmission with organ transplantation 8 .…”

“…In spite of the growing popularity of KPD, this practice has not yet caught on in South America. In this issue of the Brazilian Journal of Nephrology, Medina-Pestana et al 5 and Bastos et al 6 debate the merits and potential pitfalls of KPD. The authors of both articles summarize the literature in the field of KPD, with Bastos et al 6 coming out strongly in favor of KPD, while Medina-Pestana et al 5 express great caution not only with KPD but also with living donation and perhaps transplantation in general.…”

“…Medina-Pestana et al 5 raise several concerns, including the fear that only the wealthy will benefit and that devoting resources to promote KPD would divert attention from the deceased donor program. The authors are concerned that living donation poses potential risks to the long-term health of the donor, which may be exacerbated by a lack of medical care, especially in resource-poor countries 7 and therefore advocate for a cautious approach to living kidney donation in general.…”

“…Furthermore, with regard to living organ donors, they must decide how best to protect their interests and long-term health. By bringing awareness of KPD to the medical community in Brazil, both Medina-Pestana et al 5 and Bastos et al 6 and colleagues are furthering the cause of transplantation in their community. And if one is convinced that kidney transplantation is a life-enhancing and life-extending therapy, then KPD should be considered as an option for all transplant candidates who have a living donor who is medically able but cannot donate a kidney to the intended candidate because of ABO or human leukocyte antigen (HLA) incompatibility.…”