Donor Exchange for Renal Transplantation
http://www.100md.com
《新英格兰医药杂志》
To the Editor: The Perspective article by Delmonico (April 29 issue)1 prompts us to report on the Dutch Living Donor Kidney Exchange program. Since January 1, 2004, all seven transplantation centers in the Netherlands have cooperated in this common protocol. The Dutch Transplant Foundation is responsible for allocation on an anonymous basis, the approach generally preferred by our patients.2 Allocation is determined according to the following hierarchy of factors: blood type (first identical, and then compatible); match probability (derived from the prevalence of HLA antigens in the kidney-exchange donor pool and the unacceptable HLA antigens of the recipient); and then the wait time (calculated beginning with the first day of renal-replacement therapy).3 Since the start of this program, 32 pairs have applied to participate. The median wait time was 2.5 years (range, 0.0 to 5.0), and the median peak level of preformed antibodies at the time of application was 14 percent (range, 0 to 100). There were 13 pairs with blood-type incompatibility and 19 pairs with cross-match incompatibility. There were new combinations in 14 of the pairs (44 percent) — specifically, in 6 of the 13 pairs with blood-type incompatibility and in 8 of the 19 pairs with cross-match incompatibility.
In our opinion, exchanging donor kidneys is a form of barter and is thus vulnerable to economic forces. Therefore, we suggest that the allocation procedure be performed by an independent organization, to avoid the buying and selling of organs.
Marry de Klerk, S.W.
Erasmus University Medical Center Rotterdam
Rotterdam 3000 CA, the Netherlands
marry.deklerk@erasmusmc.nl
Karin Keizer, M.D.
Willem Weimar, M.D., Ph.D.
Dutch Transplant Foundation
Leiden 2301 CH, the Netherlands
References
Delmonico FL. Exchanging kidneys -- advances in living-donor transplantation. N Engl J Med 2004;350:1812-1814.
de Klerk M, Luchtenburg AE, Zuidema WC, Kranenburg LW, IJzermans JNM, Weimer W. Acceptability and feasibility of cross-over kidney transplantation. In: Gutmann T, Daar AS, Sells RA, Land W, eds. Ethical, legal and social issues in organ transplantation. Lengericht, Germany: PABST Science, 2004:255-62.
de Klerk M, Luchtenburg AE, Zuidema WC, et al. Feasibility of cross-over kidney transplantation for donor-recipient pairs with a positive cross-match. Am J Transplant 2003;3:Suppl 5:229-229. abstract.
To the Editor: Delmonico makes many admirable points about the need to increase the living donor population for sensitized patients who are unable to receive organs from their prospective donors because of isoagglutinin or HLA antibodies. He states that plasma-exchange protocols are expensive and are associated with an unpredictable rate of graft loss. As a practicing nephrologist and also as a recipient of three renal transplants — the most recent received under a plasma-exchange protocol — I disagree. I pursued a career in medicine, from medical school through fellowship, while undergoing peritoneal dialysis necessitated by a high titer of HLA antibodies. Estimates from the Johns Hopkins University suggest that transplantation with the use of a plasma-exchange protocol is less expensive, when analyzed three years after allografting, than maintenance dialysis for two years (Montgomery R: personal communication). With the current increased waiting times for sensitized patients and the ever increasing number of sensitized patients as repeated transplantations are performed, earlier transplantation would be financially beneficial. Both donor-exchange and plasma-exchange protocols seek to accomplish this goal, and both should continue to be supported fully.
Allan J. Goody, M.D.
Virginia Hospital Center
Arlington, VA 22205
allanjg@aol.com
To the Editor: Delmonico explains clearly the process and value of living-donor kidney exchanges for incompatible potential donor–recipient pairs, but does not emphasize the problem for people with blood type O. Since type O recipients can receive kidneys only from type O donors, and because type O donors can give a kidney to recipients of any blood type, very few type O donors and recipients would contribute to or benefit from exchanges.1,2 The most common blood type is O, greatly limiting the number of blood-type–incompatible pairs that could benefit from exchanges.3 The only way a type O donor would become available for an exchange is if he or she were incompatible with the intended recipient because of a positive cross-match, as illustrated in the figure in Delmonico's article. In that example, a type O donor who is cross-match–positive with her intended recipient is shown giving to a type B recipient. Given the limited number of type O donors available for exchanges, would it not make sense to limit the pairing of such donors to type O recipients?
Aaron Spital, M.D.
New York Organ Donor Network
New York, NY 10115
aspital@nyodn.org
References
Ross LF, Woodle ES. Ethical issues in increasing living kidney donations by expanding kidney paired exchange programs. Transplantation 2000;69:1539-1543.
Abecassis M, Adams M, Adams P, et al. Consensus statement on the live organ donor. JAMA 2000;284:2919-2926.
Terasaki PI, Gjertson DW, Cecka JM. Paired kidney exchange is not a solution to ABO incompatibility. Transplantation 1998;65:291-291.
Dr. Delmonico replies: If a kidney donor exchange can be performed without the necessity of plasmapheresis in the recipient, that approach is indisputably cost saving. If a system of donor exchange can be developed that identifies recipient pairs that have no donor alloreactivity, that approach is clinically prudent. The program of donor exchange that has been initiated by Montgomery and other groups, mentioned in my Perspective article and by Goody, is to be commended. Identifying exchange pairs whose recipients have no donor-specific antibodies before transplantation avoids the hazard of a rejection episode associated with the reappearance of donor-specific antibodies.
In the United States, these exchanges must adhere to section 301 of the National Organ Transplant Act of 1984 (NOTA), which states, "It shall be unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation." Valuable consideration according to this act has traditionally been considered to be monetary transfer or a transfer of valuable property between the donor and recipient (and in some cases an organ broker) in a sale transaction. In reply to de Klerk and colleagues, the motivation of our exchange donors has complied with federal law,1 and we support the use of an independent donor advocate.2 Furthermore, the General Counsel to the United Network for Organ Sharing, Malcolm E. Ritsch, Jr., has provided the following position statement regarding donor exchanges and valuable consideration:
The donation of an organ is properly considered to be a legal gift, rather than a contractual undertaking. By definition, there is no "consideration" at all in a gift transaction. Like all gifts, organ donations may be made for specific purposes. There is no valuable consideration under NOTA 301 in any of these living donation arrangements. In fact, there is no "consideration" present at all. The donor receives none, the recipient gives none and none is transferred to a broker.3
Perhaps someday we will have computer-driven identification of donor–recipient pairs to subscribe to Spital's suggestion of giving type O recipients priority. In the interval, we can expand the possibility of exchanges precisely as Dr. Spital asserts a limitation, by finding (as we did) a type O donor who is incompatible with the intended recipient because of a positive cross-match.
Francis L. Delmonico, M.D.
New England Organ Bank
Newton, MA 02458-2803
References
Delmonico F, Morrissey P, Lipkowitz G, et al. Donor kidney exchanges. Am J Transplant (in press).
Abecassis M, Adams M, Adams P, et al. Consensus statement on the live organ donor. JAMA 2000;284:2919-2926.
Ritsch ME. Intended recipient exchanges, paired exchanges and NOTA 301, 2003 March 7: exhibit UU (appendix 1) to Kidney & Pancreas Transplantation Committee report to OPTN/UNOS board of directors meeting in June 2003. Richmond, Va.: Williams Mullen, 2003.
In our opinion, exchanging donor kidneys is a form of barter and is thus vulnerable to economic forces. Therefore, we suggest that the allocation procedure be performed by an independent organization, to avoid the buying and selling of organs.
Marry de Klerk, S.W.
Erasmus University Medical Center Rotterdam
Rotterdam 3000 CA, the Netherlands
marry.deklerk@erasmusmc.nl
Karin Keizer, M.D.
Willem Weimar, M.D., Ph.D.
Dutch Transplant Foundation
Leiden 2301 CH, the Netherlands
References
Delmonico FL. Exchanging kidneys -- advances in living-donor transplantation. N Engl J Med 2004;350:1812-1814.
de Klerk M, Luchtenburg AE, Zuidema WC, Kranenburg LW, IJzermans JNM, Weimer W. Acceptability and feasibility of cross-over kidney transplantation. In: Gutmann T, Daar AS, Sells RA, Land W, eds. Ethical, legal and social issues in organ transplantation. Lengericht, Germany: PABST Science, 2004:255-62.
de Klerk M, Luchtenburg AE, Zuidema WC, et al. Feasibility of cross-over kidney transplantation for donor-recipient pairs with a positive cross-match. Am J Transplant 2003;3:Suppl 5:229-229. abstract.
To the Editor: Delmonico makes many admirable points about the need to increase the living donor population for sensitized patients who are unable to receive organs from their prospective donors because of isoagglutinin or HLA antibodies. He states that plasma-exchange protocols are expensive and are associated with an unpredictable rate of graft loss. As a practicing nephrologist and also as a recipient of three renal transplants — the most recent received under a plasma-exchange protocol — I disagree. I pursued a career in medicine, from medical school through fellowship, while undergoing peritoneal dialysis necessitated by a high titer of HLA antibodies. Estimates from the Johns Hopkins University suggest that transplantation with the use of a plasma-exchange protocol is less expensive, when analyzed three years after allografting, than maintenance dialysis for two years (Montgomery R: personal communication). With the current increased waiting times for sensitized patients and the ever increasing number of sensitized patients as repeated transplantations are performed, earlier transplantation would be financially beneficial. Both donor-exchange and plasma-exchange protocols seek to accomplish this goal, and both should continue to be supported fully.
Allan J. Goody, M.D.
Virginia Hospital Center
Arlington, VA 22205
allanjg@aol.com
To the Editor: Delmonico explains clearly the process and value of living-donor kidney exchanges for incompatible potential donor–recipient pairs, but does not emphasize the problem for people with blood type O. Since type O recipients can receive kidneys only from type O donors, and because type O donors can give a kidney to recipients of any blood type, very few type O donors and recipients would contribute to or benefit from exchanges.1,2 The most common blood type is O, greatly limiting the number of blood-type–incompatible pairs that could benefit from exchanges.3 The only way a type O donor would become available for an exchange is if he or she were incompatible with the intended recipient because of a positive cross-match, as illustrated in the figure in Delmonico's article. In that example, a type O donor who is cross-match–positive with her intended recipient is shown giving to a type B recipient. Given the limited number of type O donors available for exchanges, would it not make sense to limit the pairing of such donors to type O recipients?
Aaron Spital, M.D.
New York Organ Donor Network
New York, NY 10115
aspital@nyodn.org
References
Ross LF, Woodle ES. Ethical issues in increasing living kidney donations by expanding kidney paired exchange programs. Transplantation 2000;69:1539-1543.
Abecassis M, Adams M, Adams P, et al. Consensus statement on the live organ donor. JAMA 2000;284:2919-2926.
Terasaki PI, Gjertson DW, Cecka JM. Paired kidney exchange is not a solution to ABO incompatibility. Transplantation 1998;65:291-291.
Dr. Delmonico replies: If a kidney donor exchange can be performed without the necessity of plasmapheresis in the recipient, that approach is indisputably cost saving. If a system of donor exchange can be developed that identifies recipient pairs that have no donor alloreactivity, that approach is clinically prudent. The program of donor exchange that has been initiated by Montgomery and other groups, mentioned in my Perspective article and by Goody, is to be commended. Identifying exchange pairs whose recipients have no donor-specific antibodies before transplantation avoids the hazard of a rejection episode associated with the reappearance of donor-specific antibodies.
In the United States, these exchanges must adhere to section 301 of the National Organ Transplant Act of 1984 (NOTA), which states, "It shall be unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation." Valuable consideration according to this act has traditionally been considered to be monetary transfer or a transfer of valuable property between the donor and recipient (and in some cases an organ broker) in a sale transaction. In reply to de Klerk and colleagues, the motivation of our exchange donors has complied with federal law,1 and we support the use of an independent donor advocate.2 Furthermore, the General Counsel to the United Network for Organ Sharing, Malcolm E. Ritsch, Jr., has provided the following position statement regarding donor exchanges and valuable consideration:
The donation of an organ is properly considered to be a legal gift, rather than a contractual undertaking. By definition, there is no "consideration" at all in a gift transaction. Like all gifts, organ donations may be made for specific purposes. There is no valuable consideration under NOTA 301 in any of these living donation arrangements. In fact, there is no "consideration" present at all. The donor receives none, the recipient gives none and none is transferred to a broker.3
Perhaps someday we will have computer-driven identification of donor–recipient pairs to subscribe to Spital's suggestion of giving type O recipients priority. In the interval, we can expand the possibility of exchanges precisely as Dr. Spital asserts a limitation, by finding (as we did) a type O donor who is incompatible with the intended recipient because of a positive cross-match.
Francis L. Delmonico, M.D.
New England Organ Bank
Newton, MA 02458-2803
References
Delmonico F, Morrissey P, Lipkowitz G, et al. Donor kidney exchanges. Am J Transplant (in press).
Abecassis M, Adams M, Adams P, et al. Consensus statement on the live organ donor. JAMA 2000;284:2919-2926.
Ritsch ME. Intended recipient exchanges, paired exchanges and NOTA 301, 2003 March 7: exhibit UU (appendix 1) to Kidney & Pancreas Transplantation Committee report to OPTN/UNOS board of directors meeting in June 2003. Richmond, Va.: Williams Mullen, 2003.