John E. Franklin

Disparities in kidney transplant outcomes: a review.

Sociocultural and socioeconomic disparities in graft survival, graft function, and patient survival in adult kidney transplant recipients are reviewed. Studies consistently document worse outcomes for black patients, patients with low income, and patients with less education, whereas better outcomes are reported in Hispanic and Asian kidney transplant recipients. However, the distinct roles of racial/ethnic versus socioeconomic factors remain unclear. Attention to potential pathways contributing to disparities has been limited to immunologic and nonimmunologic factors, for which the mechanisms have yet to be fully illuminated. Interventions to reduce disparities have focused on modifying immunosuppressant regimens. Modifying access to care and health care funding policies for immunosuppressive medication coverage also are discussed. The implementation of culturally sensitive approaches to the care of transplant candidates and recipients is promising. Future research is needed to examine the mechanisms contributing to disparities in graft survival and ultimately to intervene effectively.

Opportunities for shared decision making in kidney transplantation

Health researchers and policy‐makers increasingly urge both patient and clinician engagement in shared decision making (SDM) to promote patient‐centered care. Although SDM has been examined in numerous clinical settings, it has received little attention in solid organ transplantation. This paper describes the application of SDM to the kidney transplantation context. Several distinctive features of kidney transplantation present challenges to SDM including fragmented patient–provider relationships, the time‐sensitive and unpredictable nature of deceased organ offers, decision‐making processes by transplant providers serving as both organ guardians (given the

The noninterference of aluminum hydroxide gel with quinidine sulfate absorption: An approach to control quinidine-induced diarrhea

Quinidine has been used in the successful treatment of cardiac arrhythmias for over two decades. However, its toxicity, including nausea, vomiting, diarrhea, and more serious problems of arrhythmias and sudden death has limited its usefulness in certain situations. Of particular note is the gastrointestinal intolerance that many patients experience. It is estimated that nausea, vomiting, and diarrhea occur in 30 per cent of patients ingesting quinidine, requiring discontinuation of therapy in as many as 10 per cent’-” These side effects are not related to dose or to blood levels. They are believed to be due to a direct stimulant action on the smooth muscle of the small intestine.’ We have encountered patients who have required quinidine for the successful control of their arrhythmias, but who could not tolerate the resulting gastrointestinal symptoms, particularly diarrhea. Concomitant administration of aluminum hydroxide gel with their quinidine dose resulted in reduction of diarrhea, with apparently continued control of their arrhythmias. Previous reports of interference with drug absorption by antacids prompted a study to determine the effects of aluminum hydroxide gel on quinidine absorption.”

The Challenge of Informed Consent for Increased Risk Living Donation and Transplantation

The Organ Procurement and Transplantation Network (OPTN) mandates that organ recipients provide “specific informed consent” before accepting organs that the OPTN defines as “increased risk”. However, the OPTN does not provide specific guidelines for what information should be disclosed to potential recipients. Such vagueness opens the door to inadequate informed consent. This paper examines the ethical dimensions of informed consent when the prospective living donor has self‐reported behaviors associated with increased risk for infection transmission. Donor privacy is a primary ethical concern that conflicts with recipients’ informed consent for use of increased risk organs. We propose that both the increased risk status and the specific behavior be disclosed to the recipient. Because the actual risk posed is linked to the type of risk behavior, disclosure is therefore needed to make an informed decision. The donors risk behavior is material to recipients’ decision making because it may impact the donor–recipient relationship. This relationship is the foundation of the donation and acceptance transaction, and thus comprises a critical feature of the recipients informed consent. Optimizing a recipients informed consent is essential to protecting patient safety and autonomy.

When Duties Collide: Beneficence and Veracity in the Evaluation of Living Organ Donors

Purpose of reviewAlthough the medical excuse is routinely used by many transplant programs, ethical issues arising from its use have received little critical attention. The present review will define the medical excuse and briefly discuss its history, purposes, and use in the context of evaluating donor candidates, and will provide a framework for evaluating some of the ethical issues related to its use through consideration of, and comparison with, ethical issues arising from the use of deception in medical practice. Recent FindingsNo empirical evidence supports or contradicts claims about whether using the medical excuse in transplantation fosters the short-term or long-term benefits or harms commonly attributed to it. The literature on using deception in medical practice provides illustrative comparisons and suggests the medical excuse may have ramifications not yet well understood. SummaryThe medical excuse is used by many transplant programs to assist or usher donor candidates out of donation. The present review explores ethical issues that may arise from maintaining or abandoning this practice, and suggests that it merits further empiric and analytic attention from the transplant community.

The Commercialization of Human Organs for Transplantation: The Current Status of the Ethical Debate

Purpose of reviewWhether financial or other incentives for organs should be allowed or prohibited is one of the most challenging ethical issues facing the transplant community. This review provides an overview of the current status of the ethical debate on this issue. Recent findingsCurrently, the buying and selling of organs from either living or deceased donors is legally prohibited in many parts of the world in order both to prevent the commercialization of organs and to ensure some level of equity of access to organ transplantation. Still, a number of proposals have been put forth in recent years suggesting that some form of financial compensation (e.g. direct payment, reimbursement, tax credits) or other ‘moral’ incentives (e.g. honorary medals) should be permitted or explored. An emerging issue that has recently received considerable attention is public solicitation of organs from living and deceased donors through commercial venues, which is seen by some as a potential means for the wealthy to gain an unfair advantage in obtaining an organ. SummaryThis review tracks the ethical debate regarding the commercialization of organs along a ‘commercialization continuum’, with direct payment for organs at one end and public solicitation at the other.

In response to: Testa et al. 'Elective surgical patients as living organ donors: A clinical and ethical innovation'

A justification for previous innovations in donor transplant surgery, such as laparoscopic nephrectomy, was reduced donor morbidity while possibly increasing donations. The justification for the proposed innovation is increasing the organ supply while reducing the number of surgeries to achieve this aim; yet it does not help the donor. It is unclear whether these benefits outweigh the violation of the ’no harm’ principle. Cholecystectomy donors may have greater morbidity due to the bigger dissection for the nephrectomy, including surgical complications and will lack some of the benefits experienced by emotionally related donors.

Barriers to the Implementation of a Program for Inner-City, Homeless Substance Abusers on General Assistance: Newark

The article describes the implementation of a comprehensive rehabililation program for homeless subslance abusers within an inner-city setting. The program was a joint effort between a university research team and the general welfare deparlment of Ihe City of Newark, NJ. A description of the program is followed by a discussion of the political, economic, philosophical and bureaucratic barriers towards implementation of the project. Strengths and weaknesses of multiple agency efforts to rehabilitate homeless substance abusers are discussed. Complex systems issues that may be generalizable to other similar settings are highlighted. Conclusions and recommendations for implementation of future projccts are presented.

Psychosocial issues in inflammatory bowel disease and intestinal failure

Current research about psychosocial issues related to inflammatory bowel disease (IBD) is limited. Studies are often small, uncontrolled, or poorly designed.