Transplants: Keeping Donors Safe
Back in 1995, there were about 3,000 living kidney donors. Last year, that number shot past 6,500. More live donors is a good thing for transplant recipients, since live kidneys work better than dead ones. But the rapidly growing numbers have raised thorny ethical issues that transplant surgeons haven't faced with cadaver kidneys: questions about donor safety and psychological motives that keep people in the transplant community awake late at night.
"I can't think of anything that makes me more concerned than these operations on live donors," says surgeon Andrew Klein, director of the comprehensive transplant center at Cedars-Sinai Medical Center in Los Angeles. "You're taking a healthy person and making them unwell."
Klein means that abdominal surgery for four or five hours, which is what it takes to remove a kidney, is not a walk in the park. It's a major operation. There's even a slim chance of death–0.03 percent, to be precise. Though donors desperately want to do it, because it usually means saving the life of a loved one, surgery is not to be taken lightly.
Nor is life after surgery. "Their lives should be fairly normal, but there are a few things to watch," says Hamid Rabb, a nephrologist (a kidney specialist) at Johns Hopkins Hospital in Baltimore. "We tell them to avoid contact sports, because they need to guard their remaining kidney. And don't take large amounts of drugs like Advil or other nonsteroidal anti-inflammatories (NSAIDs). That's triggered irritation of the kidney in a few people. But it goes away once they stop the drugs."
But Rabb also notes there are things doctors don't really know about the long term. "It's often said that donors actually live longer than other people, but that's kind of misleading, because we select only the healthiest people to donate, so you'd expect them to live longer than average." And there have not been any large studies that follow people from donation through the next 20 or 30 years. "Right now, I know there are at least 40 former donors who are on the national kidney transplant registry, waiting for an organ themselves. Maybe that's nothing in the scheme of an entire population"–there are nearly 70,000 people on the kidney registry–"maybe that had nothing to do with donating an organ, but we can't ignore it, either." Rabb and colleagues at the Mayo Clinic and the University of Minnesota have just started a study that will follow donors for several years to answer some of these nagging questions.
There are also psychological concerns about donors, especially with new kidney swap procedures in which people donate to strangers in exchange for another stranger giving a kidney to their loved one. Another new wrinkle is when donors and recipients connect through websites that try and match them up like a dating service. "Are they truly giving freely? Are they taking all their own needs into account and the needs of their own family?" asks David Edwin, a psychologist who works in the Hopkins transplant program. He puts donors through exhaustive interviews and psychological tests, looking for trouble signs. A history of eating disorders such as bulimia, or repeated episodes of depression, can spell problems. "People shouldn't see donating as a way to treat their own depression, to improve their self-esteem, for instance," Edwin says.
And all programs are very concerned about donors succumbing to outside pressures to give up a kidney. "I've had patients say things like 'I don't want to do this but if I don't, I'm out of the will,'" says Edwin. He gives such people a "get out of jail free" card: telling their families that the person can't donate for medical reasons. It removes the pressure and leaves everyone with dignity intact.
To guard against pressure from the hospital itself–transplant programs like to do transplants, after all–the United Network for Organ Sharing, the federally funded nonprofit agency that matches donors and recipients, has issued guidelines that say at least one member of a hospital's transplant team should be assigned solely to the donor and have no connection to the recipient. This is to assure the donor's interests come first. At Cedars-Sinai, the hospital uses a gastroenterologist who doesn't work in the transplant center. "Our goal is to protect the donor," says Klein. "And I think we've been very successful doing that."