Transplantation: changing peoples’ attitudes to became donors: difficulties and challenges

Federico Oppenheimer Servei de Nefrologia i Trasplantament Renal

Hospital Clínic de Barcelona

oppen@clinic.cat

Modalities of Donor-Recipient

Relationships

Genetically related

Parent

Sibling

Offspring

Other (grandparent, etc)

Emotionally related

Spouse

Adoptive parent

Friend

Paired exchange

Altruistic

Genetically related

Identical twins

HLA-identical siblings

HLA-haploidentical

Others

Genetically unrelated

Previous pregnancy-related

donors (husband / offspring)

ABO-incompatible

HLA-incompatible

Immunological matching Relationship

Benefit Risk

Donor Recipient

Living Donor Kidney Transplantation

Society

Decreased risk of mortality

Improved graft survival

Avoidance or reduction of dialysis

Alleviates deceased donors shortage

Reduces cost of ESRD treatment

Unnecessary risk of mortality

morbidity

Physical or emotional sequels

Life Kidney Donor Programmes

Stakeholders Patients

Families and other relatives

Nephrology and Transplant professionals

Health care providers

Government and Administration

Actors Patients

Potential donors

Nephrology and Transplant professionals

Other hospital professionals

Ethical committees

Legal procedures

Health Administration

0 20 40 60 80 100

Enough deceased donors offer

Fear of failure

Concerns about donor safety

Families are not motivated

Haven’t been interested

Opinion survey on renal donation from living donor

35 kidney transplant units in Spain

1994

Reasons for not doing LOD Kidney Transplants

Arias M and de Felipe C. Nefrologia 1995, 15 (6): 523-8

Opinion survey on renal donation from living donor

732 Hospital Professionals in Spain (41.6% nurses)

2004

Reasons for the low number of LOD Kidney Transplants

Alvarez M et al. Nefrologia 2005, 25 (Supl. 2): 57-61

8,3

24,2

27

16,6

4,5

6,8

7,8

4,5

0 5 10 15 20 25 30

Lack of resources and infrastructure

Lack of professional awareness

Lack of families and patients awareness

Acceptable time awaiting for a DD

Bureaucratic obstacles

Ethical concerns

NN / NA

Other

Opinion survey on renal donation from living donor

732 Hospital Professionals (41.6% nurses) and 416 patients

2004

Do you have information about LOD?

25

59

16

Yes No Dont' Know

16,6

83,4

Yes No

Does the medical team have

offered to you the LOD as an

option?

Patients answers

Alvarez M et al. Nefrologia 2005, 25 (Supl. 2): 57-61

Ways of living donation promotion

Direct promotion Nephrology professionals

Patient’s education programs

Patients associations

Governments

Increasing public awareness Traditional mass media: TV-Radio, newspapers

Cinema

New social media: Internet, Facebook

Growth over time in the percentage of transplant centers willing to accept friends and altruistic strangers as kidney donors

129 US Transplant Centres

Spital A. Transplantation 2000, 69 (8): 1728-31

“Facebook is already being used to identify potential kidney donors. Future studies should focus on how to safely, ethically, and effectively use social networking sites to inform potential donors and potentially expand live kidney donation“

Accepting unrelated donors

• Before considering the potential unrelated donor, the transplant team has to assess that no suitable related donors are available

• Psychological and basic medical evaluation

• Transplant coordinator interview

• Anticipated presentation to the Ethics Committee

Maximizes the number of potential donors

Information arrives to every potential donor

Increases the probability of pre-emptive transplantation

Improves HLA-matching selection

Increases the risk of involuntary coercion

Based on donor motivation:

Decreases the risk of coercion

Reduces the pool of potential donors

Limitations in HLA-matching

Medical team-oriented:

Increases the pool of potential donors

Increases the risk of involuntary coercion

How to approach potential donors

Who should approach the potential donor?

Anonymous questionnaire to There were 168 health care professionals and 296 patients

Mazaris EM et al Nephrol Dial Transplant (2012) 27: 2517–2525

Implementing a living organ donor team significantly increases the number of transplantations performed

Cardinal et al. Canadian Journal of Kidney Health and Disease (2015) 2:15

The LOD team promotes LOD at its

own and referring centres, coordinates

assessments of living organ donors,

facilitates the process, and ensures

long-term follow-up after the donation

0

10

20

30

40

50

60

70

19

65

19

67

19

69

19

71

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73

19

75

19

77

1979

19

81

19

83

19

85

19

87

19

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97

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20

01

20

03

20

05

20

07

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15

798

Hospital Clínic Barcelona Living Donor Kidney Transplantation Activity

Initiatives to increase LOD kidney transplants

To sensitize Nephrologist and nurses in care of patients

with advanced renal failure

Patient and families information and education

Information leaflets

Meetings with previous donors

To include LOD transplant as part of the routine

information before starting dialysis

To consider LOD program as part of the hospital’s

strategic plan

Initiatives to increase LOD kidney transplants

Multidisciplinary evaluation team meetings:

- Transplant Nephrologists and Nurses

- Urologists

- Transplant Coordinators

- Immunologists

- Radiologists

- Anaesthesiologists

- Hemotherapist (plasmapheresis)

- Social workers

- Eventually: Cardiologist, Cardiovascular surgeon, Psychiatrist, etc.

All donor and recipient evaluations should be presented and approved by the

multidisciplinary team during the meeting

Conclusions

Proactive strategies are necessary to expand all modalities of LKT including

unrelated donors, ABO- and/or HLA-incompatible donors and altruistic or paired-

exchange donation

A crucial period in defining the potential LKT alternatives is during the pre-

dialysis stage

Systematic information about LKT as part of the ESRD treatment options is

mandatory

All the stakeholders, in particular Nephrologist and transplant professionals,

health care providers and governments have to collaborate in sensitizing the

society about the need for living donation

Thank You!