Aaron Spital

PUBLIC ATTITUDES TOWARD KIDNEY DONATION BY FRIENDS AND ALTRUISTIC STRANGERS IN THE UNITED STATES

Background. A severe shortage of organs is one of the major barriers facing transplantation today. One promising approach to this serious problem is to increase the use of genetically unrelated living kidney donors. Because of excellent results and favorable ethical considerations, spousal donation has become a widely accepted practice in the United States. The majority of U.S. transplant centers are now also willing to consider friends as donors, but they seem to be less comfortable about this donor source and most centers are opposed to using strangers. This study was designed to see what the public thinks about these issues. Methods. A telephone survey of 1009 randomly selected adults living in the U.S. was conducted by the Gallup Organization. The survey asked about the acceptability of kidney donation by close friends and altruistic strangers and the willingness of respondents to make such donations themselves. Results. Over 90% of respondents believe that kidney donation by close friends is acceptable and 80% feel the same way about kidney donation by altruistic strangers. Most respondents (76%) would probably donate a kidney to a close friend with renal failure and 24% said they would even donate a kidney to a stranger for free. Conclusion. It seems that the vast majority of American adults believe that living kidney donation by friends and altruistic strangers is an acceptable practice and many would consider making such donations themselves. When considered along with excellent results and favorable ethical arguments, these data suggest that kidney donation by friends and altruistic strangers should be considered as acceptable as is donation by spouses.

Evolution of attitudes at U.S. transplant centers toward kidney donation by friends and altruistic strangers.

A severe shortage of organs is one of the major barriers facing transplantation today. One of the proposals designed to overcome this serious problem is to increase the use of genetically unrelated living kidney donors. Excellent results have been achieved with these volunteers and cogent arguments have been made that this practice is ethically acceptable. These considerations have encouraged many transplant centers to break with tradition and accept spousal donors. To see if there has been a similar change in attitudes toward other types of unrelated living donors, a survey was mailed to 208 U.S. renal transplant centers; 129 (62%) were returned. Ninety-three percent of responding centers said they would accept a close friend as a kidney donor. Although the majority of centers would not consider an altruistic stranger, a sizeable minority (38%) would. When compared with the results of previous surveys, these data show that attitudes toward unrelated living kidney donors have gradually become much more liberal.

Should all human immunodeficiency virus-infected patients with end-stage renal disease be excluded from transplantation? The views of U.S. Transplant Centers

BACKGROUND Human immunodeficiency virus (HIV)-infected patients have generally been excluded from transplantation. Recent advances in the management and prognosis of these patients suggest that this policy should be reevaluated. METHODS To explore the current views of U.S. transplant centers toward transplanting asymptomatic HIV-infected patients with end-stage renal disease, a written survey was mailed to the directors of transplantation at all 248 renal transplant centers in the United States. RESULTS All 148 responding centers said they require HIV testing of prospective kidney recipients, and 84% of these centers would not transplant an individual who refuses HIV testing. The vast majority of responding centers would not transplant a kidney from a cadaveric (88%) or a living donor (91%) into an asymptomatic HIV-infected patient who is otherwise a good candidate for transplantation. Among the few centers that would consider transplanting an HIV-infected patient, not a single center had performed such a transplant in the year prior to the survey. Most centers fear that transplantation in the face of HIV infection would be harmful to the individual, and some believe that it would be a waste of precious organs. CONCLUSIONS The great majority of U.S. renal transplant centers will not transplant kidneys to HIV-infected patients with end-stage renal disease, even if their infection is asymptomatic. However, advances in the management of HIV infection and a review of relevant ethical issues suggest that this approach should be reconsidered.

Mandated Choice: A Plan to Increase Public Commitment to Organ Donation

OBJECTIVES To estimate the impact of mandated choice--a system that requires competent adults to decide prospectively whether or not they wish to be organ donors when they die--on public commitment to organ donation; and to explore who is best suited to provide consent--the family or the individual? DESIGN A national, random-digit telephone survey conducted by the Gallup Organization in July 1993. PARTICIPANTS A representative sample (n = 1002) of adults (aged 18 years and older) living in homes with telephones in the continental United States. RESULTS Although the majority of respondents had given at least some thought to organ donation, only 25% had carefully considered this issue. Overall, 30% had decided to donate, but 58% were undecided and only 38% had made their wishes known to a family member. Yet the vast majority (82%) believes that the best way to obtain consent is for each adult to decide for himself or herself, rather than leaving this decision for the family. Under mandated choice, which is designed to encourage such self-determination, 63% would sign up to donate, 24% would not, and 13% were unsure. CONCLUSIONS Only a small fraction of the US public is currently committed to organ donation and relatively few people have carefully considered and communicated their wishes regarding this important issue. Therefore, the difficult question of consent is often left for the family. Yet most people believe that ideally all adults should answer this question for themselves, in contrast to our present family-oriented approach, but consistent with the design of mandated choice. If mandated choice became law, it appears that most adults would sign up to donate, thereby increasing the pool of desperately needed committed donors.

Unrelated living kidney donors : an update of attitudes and use among U.S. transplant centers

A severe shortage of organs is perhaps the most important obstacle facing transplantation today. In an attempt to address this serious problem, several transplant centers have suggested a reconsideration of genetically unrelated living kidney donors. Recently, there have been reports of excellent results using such unconventional donors, and cogent arguments have been made that this approach is ethically acceptable, at least when the donor is motivated by altruism. To see what impact this new information has had on the transplant community, I mailed a questionnaire to all adult renal transplant centers in the United States asking for their views and practices regarding unrelated living kidney donation. Of the 127 (64%) responding, 88% would accept spouses as donors, 63% would accept friends, and 15% would even consider altruistic strangers. When compared with the results of a similar survey completed six years ago, it became clear that support for unrelated living kidney donation had increased, as the great majority of centers now believe that emotionally related donors are acceptable. On the other hand, while more of these donors are being used, they still account for only a small fraction of all kidney transplants. It appears that medical successes and favorable ethical arguments have generated broad support for some types of unrelated living donors, but more in principle than in practice, as there still seems

Should people who donate a kidney to a stranger be permitted to choose their recipients? Views of the United States public.

Background. Several transplant centers have begun to accept kidneys donated by altruistic living strangers. Many of these centers insist that such donations be nondirected, meaning that the donors may not choose their recipients. On the other hand, some authors have argued that anonymous donors should be allowed to select their recipients. This study was designed to explore public attitudes toward this issue. Methods. Two telephone surveys of US adults, each including more than 1,000 participants, were conducted. The first asked about the general acceptability of allowing altruistic strangers to direct donations, the willingness to donate a kidney to a stranger, and the impact of permitting directed donation on willingness to give. The second survey asked about the acceptability of directed donation to members of specific groups. Results. About one quarter of the respondents said they would donate a kidney to a stranger for free, and the vast majority of them would donate even if they could not choose their recipients. Two thirds would not allow anonymous kidney donors to direct their gifts to a member of a specific racial or religious group, but three quarters would support kidney donations directed to children. Conclusions. These data support the current policy of several transplant centers that people who wish to donate a kidney to a stranger are not permitted to choose their recipients on the basis of membership in a racial or religious group. On the other hand, theoretical considerations and the results of this study suggest that people who wish to donate a kidney only to an unknown child should be permitted to do so.

Potassium Supplementation via the Dialysate in Continuous Ambulatory Peritoneal Dialysis

A small percentage of patients treated with continuous ambulatory peritoneal dialysis (CAPD) may become hypokalemic. Since both the intravenous and oral routes for potassium repletion have disadvantages, we studied the feasibility, effectiveness, and safety of acute potassium loading via the dialysate in patients on CAPD. Five patients were studied during an exchange containing 20 mEq/L of potassium. This was well tolerated and led to a gradual increase in the plasma potassium concentration (.44 +/- .11 mEq/L) as about three-fourths of the intraperitoneal load was absorbed, most of it by two hours. The greatest increase in the plasma potassium concentration was .63 mEq/L. A separate patient developed intense abdominal pain during an exchange containing 40 mEq/L of potassium. We conclude that the dialysate is a safe and effective route for acute potassium repletion during CAPD when the dialysate potassium concentration does not exceed 20 mEq/L.

Nondilated Obstructive Uropathy

Four patients presented with severe renal failure secondary to urinary tract obstruction, yet ultrasonography and/or computed tomography revealed only minimal dilatation in 1 patient and no dilatation in the other three. Two patients had prostate cancer, one had bladder cancer, and one had retroperitoneal fibrosis. In all cases, relief of obstruction led to a dramatic improvement in renal function. These cases, and others in the literature, illustrate that in certain settings severe urinary tract obstruction may be present in the absence of dilatation and hence may be missed by noninvasive imaging techniques. Nondilated obstructive uropathy should be suspected in any elderly patient who presents with the acute onset of oliguria in the absence of an identifiable cause, especially if there is a previous history of malignancy in the pelvis. Left undiagnosed, this potentially reversible cause of renal failure can lead to end-stage renal disease.

Unconventional living kidney donors--attitudes and use among transplant centers.

The organ shortage remains a major barrier to renal transplantation in the United States today. The use of unconventional living donors, including genetically unrelated adults and related minors, could help increase the number of kidneys available for transplantation. Although these donor sources had generally been discarded, recent developments (including improved success and the demonstration of minimal risk) have caused some to reconsider this policy. Therefore, we surveyed all U.S. transplant centers regarding their attitudes toward unconventional living kidney donors. Of the nearly 60% responding: 76% would consider using spouses and 48% would even consider adult friends; 64% would consider using monozygotic twin minors and 43% would consider closely related non-twin minors; the mean minimum donor age accepted was 16 +/- 3 years, and the range was wide. On the other hand, many centers expressed reservations about these donor sources and indicated that such donors are seldom used. We conclude that under certain circumstances many U.S. transplant centers would consider accepting unconventional living kidney donors. Yet, at the same time, the centers appear uneasy about actually using these donors and no clear consensus exists. Our data indicate a need to openly readdress these issues.

Do U.S. transplant centers encourage emotionally related kidney donation

Stimulated by a severe organ shortage and an improving ability to successfully transplant poorly matched donor-recipient pairs, many transplant centers are now willing to accept emotionally related (but genetically unrelated) people (e.g., spouses) as kidney donors. To see whether this practice is encouraged, a survey was mailed to all 209 adult renal transplant centers in the United States. Of the 154 (74%) responding centers, 90% said they accept emotionally related donors and 60% said they actually encourage this practice. Nearly 40% prefer spouses to cadavers, while only 21% prefer friends to cadavers. To further explore the degree to which emotionally related donation is encouraged, a second questionnaire was sent to a sample of centers (n = 51) that support this practice; 94% responded. While only 44% said they encourage the use of friends, nearly all of these preselected centers said they encourage spouses to donate. On the other hand, judging from their stated approach to this issue, only about half of these supportive centers seem to actively encourage emotionally related donation. These data suggest that, overall, at most only about one third of U.S. transplant centers actively encourage spousal donation and at most about one quarter encourage the use of friends. Consistent with these results, emotionally related donors contribute only a small fraction of all kidneys transplanted in this country. If the large potential contribution of emotionally related donors is ever to be realized, transplant centers must go beyond simply accepting such individuals and begin to actively encourage their participation. Medical and ethical considerations strongly support this proposal.