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In this research, it was aimed to evaluate of social and community factors effective in increasing the number of liver donors. Descriptive and relational scanning models were used to conduct the research. Data on liver donors was gathered from the USA Health Resources & Services Administration's Organ Procurement and Transplantation Network between 1988 and 2023. The United States (USA) World Bank Country Reports provided the mortality rates. The data was analyzed using Spearman rho correlation, year-controlled partial correlation, and Generalized Linear Model-Logit analysis. Deceased donor numbers were significantly and negatively correlated with government health expenditure (r = -0.816; P < .01), current health expenditure (r = -0.768; P < .01), female education attainment (r = -0.804; P < .01) and Gini index (r = 0.434; P < .05). Living donor numbers were significantly and negatively correlated with government health expenditure (r = -0.731; P < .01), current health expenditure (r = -0.781; P < .01), male percentage (r = -0.786; P < .01), female education attainment (r = -0.640; P < .05), employment (r = 0.751; P < .01), GDP (r = -0.792; P < .01) and Gini index (r = -0.486; P < .01). Living donor numbers were significantly and positively correlated with age dependency (r = 0.815; P < .01). Generalized Linear Model-Logit (GLM-L) results showed that effect of female education attainment had significant contribution on deceased liver donor (B = -3290.605; P < .01). Effects of significantly correlated community factors on living liver donor numbers were found to be statistically insignificant (P > .05). Research findings reveal that among community factors, especially women's participation in education has a statistically significant effect on liver donors. These results show that the health expenditures made over the years do not provide any added value for liver donors, and role of women on liver donor is significantly dominant., Competing Interests: Author decelerates no conflicts of interest., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

This study investigated the relationship between self-determination, physical health status, and Health related Quality of Life (=HRQoL) among living kidney donors. A descriptive survey was conducted between 2019 and 2020 and included 111 kidney donors. Data were collected using a self-report questionnaire on general and donation-related characteristics, self-determination, and HRQoL. The data also included medical records reflecting the physical health status at the time of the survey. Data were analyzed using a multiple regression model. Factors associated with HRQoL were perceived health recovery after donation (β = 0.42, P < .001), up to 1 year since donation (β = 0.33, P = .008), more than 1 up to 5 years since donation (β = 0.52, P < .001), more than 5 up to 10 years since donation (β = 0.53, P < .001), and competence of self-determination (β = 0.23, P = .033). The explanatory power of these variables was 43.3%. HRQoL of living kidney donors can be affected by subjective and psychological factors. Therefore, health care providers should help living kidney donors have high self-determination during pre and post donation and concentrate on the subjective and psychological factors as well as objective health status., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Cosmetic appearance is a major concern for living donors. However, little is known about the impact of a surgical scar on body image changes in living liver donors. The aim of this study was to identify potential factors that cause displeasing upper midline incision scar, and to evaluate the overall satisfaction regarding body image and scarring after living donor hepatectomy.Donors who underwent right lobe hepatectomy were recruited. Exclusion criteria included reoperation, refusal to participate, and lost follow-up. All donors were invited to complete the Vancouver Scar Scale (VSS) and the body image questionnaire. According to the VSS results of upper midline incision scar, donors were divided into 2 groups: good scarring group (VSS ≤4) and bad scarring group (VSS >4). we compared the clinical outcomes, including the demographics, preoperation, intraoperation, and postoperation variables. The study also analyzed the results of the body image questionnaire.The proportion of male donors was 48.9%. The bad scarring group consisted of 63% of the donors. On multivariate analysis, being a male donor was found to be an independent predictor of a cosmetically displeasing upper midline incision scar with statistical significance. The results of body image questionnaires, there were significant differences in cosmetic score and confidence score among the 2 groups.The upper midline incision and male donors have higher rates of scarring in comparison with the transverse incision and female donors. Donors who reported having a higher satisfaction with their scar appearance usually had more self-confidence. However, the body image won't be affected. Medical staff should encourage donors to take active participation in wound care and continuously observe the impact of surgical scars on psychological changes in living liver donors., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose of Review: Organ shortage forces those responsible to streamline allocation rules to provide a maximum of candidates with a graft and to optimize transplant outcome. Recently, repeated kidney re-transplantation was investigated in several studies with different analytic settings concerning the control group, the donors, parameters influencing outcome, and demographic characteristics. This review gives an overview on the candidates awaiting a repeated re-transplantation, summarizes the outcome, and comments on the relevance of these findings in the context of sustained organ shortage., Recent Findings: Repeated kidney re-transplantation is technically and immunologically feasible and the recipients' survival is better compared to candidates remaining on dialysis or on the waiting-list. However, the outcome is mainly reported to be worse as compared to first or second kidney transplantation. Kidneys from living donors seem to have a favorable impact on outcome in this setting., Summary: The survival benefit of repeated re-transplantation recipients over patients on dialysis demands for continuation of this procedure. Comprehensive registries are essential to continuously optimize allocation. Governmental authorities are obliged to set the course to increase organ donation rather than forcing transplant decision makers to withhold a third or fourth graft from any candidate., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: Living kidney donation has been an established practice for many years. Although studies from the past decade have uncovered risks to the donor, living kidney donation is still promoted. In this review, the most recent studies are summarized., Recent Findings: Retrospective studies with long follow-up have detected an increased risk of hypertension among donors. Donors with hypertension at the time of donation may be at increased risk of adverse outcomes, but results differ. Recent studies have not found increased long-term mortality, but follow-up is short and control groups are of different quality., Summary: In all, the most recent findings more or less corroborate previous knowledge in the field of living donation. There is still a need for new studies on mortality with appropriate control groups and long enough follow-up., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: Living donation has a tremendous impact in bridging the gap between the shortage of organs and the growing list of transplant candidates but remains underutilized as a percentage of total transplants performed. This review focuses on obesity and social determinants of health as potential barriers to the expansion of living kidney donation., Recent Findings: The growing rate of obesity and associated metabolic syndrome make many potential donors unacceptable as donor candidates because of the future risk for developing chronic health conditions, such as hypertension and diabetes. There is also increasing evidence demonstrating socioeconomic differences and racial disparities potentially limit access to living donation in certain populations. These potentially modifiable factors are not exclusive of each other and together serve as significant contributing factors to lower rates of living donation., Summary: Living donors make sacrifices to provide the gift of life to transplant recipients, despite the potential risks to their own health. Studies describing risk factors to living donation call attention to the overall need for more action to prioritize and promote the health and well being of living donors.

Background: The cellular infiltrate in protocol liver biopsies (PB) following pediatric liver transplantation remains mostly uncharacterized, yet there is increasing concern about the role of inflammation and fibrosis in long-term liver allografts. We aimed to define cell types in PB and to analyze their relationship with donor-specific antibodies (DSA) and histological phenotype., Methods: PB were performed at least 1 year after transplantation. We identified 4 phenotypes: normal, fibrosis, inflammation, inflammation with fibrosis. Cell types were counted after immunostaining for CD3, CD4, CD8, CD68, CD20, MUM1, and FoxP3., Results: Forty-four patients underwent 1 PB between 2000 and 2015. Eleven percent (5/44) of PB displayed normal histology, 13.6% (6/44) fibrosis, 34.1% (15/44) inflammation, and 40.9% (18/44) inflammation and fibrosis. The main cell types in the portal tracts and lobules were CD3+ and CD68+ cells. Frequency of de novo DSA was 63% (27/44). The presence of CD8+ cells in the lobules was associated with fibrosis. Inflammation and fibrosis in PB were associated with the presence of circulating de novo DSA, number of de novo DSA, and C1q binding activity when compared to other phenotypes., Conclusions: T cells (CD3+) and macrophages (CD68+) were the most prevalent cell-types in PB. In the presence of inflammation, portal tracts were enriched in CD3+, CD20+ but displayed fewer CD68+. This coincided with the presence and number of de novo DSA. How these cellular and humoral actors interact is unclear, but peripheral DSA may be a marker of immune cellular activity in the seemingly quiescent allograft.

Purpose of Review: Donor-derived disease with Mycobacterium tuberculosis (MTB) is likely to become more common as donor pools expand due to increasing transplant volume coupled with patterns of migration and global mobility. Our article reviews the current literature and provides a rational approach for clinicians managing the scenario of a living donor who has epidemiologic risk factors for tuberculosis exposure., Recent Findings: Tuberculous bacilli, formerly thought to exist latently only in pulmonary granulomas, are now known reside dormant in nonpulmonary organs. Kidney and liver grafts are thus vectors for donor transmitted MTB disease. Donors with elevated risk for latent MTB disease can be identified with tuberculin skin testing or IFN-γ release assay screening in combination with a thorough history to identify risk factors for latent disease., Summary: Living donors with an elevated risk for prior MTB exposure provide an opportunity to treat latent disease prior to organ procurement and reduce the risk of donor transmitted disease and secondary morbidity. Improved identification of these high-risk donors can reduce both the incidence of posttransplant MTB disease and the risk of allograft compromise associated with treatment of latent and active disease in posttransplant recipients.

Purpose of Review: With the advent of direct acting antiviral (DAA) therapy, the use of organs from hepatitis C virus infected (HCV+) donors is gaining more traction. In this review, we aim to: provide an overview of recent literature that supports the use of HCV+ organs, outline ongoing challenges to the use of these organs, and highlight the areas within this field where active investigation is ongoing., Recent Findings: The present review describes clinical outcomes related to the transplantation of both HCV+ nonviremic and viremic organs and the distinction between hepatic and nonhepatic transplants. It also discusses the current debate pertaining to the ideal treatment strategy for donor-derived HCV infection, that is pre-emptive therapy versus prophylaxis therapy., Summary: Data suggest that the use of HCV+ organs is an effective and relatively well tolerated strategy to combat the organ scarcity. However, clinicians must be vigilant to a signal of increased inflammation as HCV+ organ transplantation becomes more universal. Recent studies suggest that shorter courses of DAA may sufficiently treat donor-derived HCV infection, however the best treatment approach to minimize risk, cost, and toxicity is still under investigation.

Background: Donor factors can influence decision making for organ utilization for potential kidney transplant candidates. Prior studies exploring the effect of donor-recipient sex matching on kidney transplant outcomes have reported heterogenous and conflicting results. The aim of this contemporary population-cohort analysis was to explore the effect of donor-recipient sex matching on kidney transplant outcomes in the United Kingdom., Methods: In this retrospective, observational study, we analyzed all patients receiving kidney-alone transplants between 2003 and 2018 using UK Transplant Registry data. Stratified by recipient sex, outcomes were compared between male and female donors with univariable/multivariable analyses., Results: Data were analyzed for 25 140 recipients. Of these, 13 414 (53.4%) of kidneys were from male donors and 15 690 (62.4%) of recipients were male. The odds of initial graft dysfunction (delayed graft function/primary nonfunction) were significantly lower for female donor kidneys transplanted into both male (adjusted odds ratio = 0.89, 95% confidence interval [CI] = 0.80-0.98, P = 0.019) and female (adjusted odds ratio = 0.81, 95% CI = 0.71-0.93, P = 0.003) recipients. Male recipients of female donor kidneys had creatinine levels at 1 year that were 6.3% higher (95% CI = 4.8%-7.7%, P < 0.001) than male recipients of male donor kidneys, with a similar sex difference of 4.1% (95% CI = 2.1%-6.1%, P < 0.001) observed within female recipients. However, neither patient nor graft survival was found to differ significantly by donor sex on either univariable or multivariable analysis., Conclusions: Our data provide contemporary data on sex mismatch for recipient counseling and reassurance with regards to equivalent long-term clinical outcomes based upon donor sex.

Background: Understanding the outcomes and risks for live kidney donors (LD) is increasingly important; this study investigated all-cause mortality and morbidity outcomes of LD compared with a healthy cohort., Methods: Live donor dataset was obtained from the UK Transplant Registry and a comparator nondonor cohort selected from The Health Improvement Network (THIN) database, a UK primary healthcare database. All LD from January 1, 2001, to December 31, 2013, were included, with follow-up until December 31, 2016., Results: There were 9750 LD and 19 071 THIN participants. Median follow-up (interquartile range) for LD was 8.4 (6.0-11.3) years and for THIN was 5.4 (2.6-8.5) years. In up to 15 years, follow-up end-stage renal disease was observed in 1 LD versus 7 THIN (P = 0.280). Nine LD had estimated glomerular filtration rate of <30 mL/min/1.73 m versus 43 in THIN (P = 0.012), but no statistically significant difference in adjusted logistic regression analyses. Risk of diabetes mellitus, depression, and cardiovascular disease was significantly higher for THIN cohort in adjusted analyses. The risk of hypertension was higher for LD at 5 years but was not significantly different in fully adjusted analyses at 10 years. There were 68 deaths in LD and 485 in THIN over the follow-up period, with significant difference in mortality favoring LD (P < 0.001)., Conclusions: The medium-term morbidity and mortality outcomes of live donors in comparison with a healthy cohort suggest that live donation is not associated with excess mortality, end-stage renal disease, or morbidity, in at least 10 years follow-up.

Background: Recipients of kidneys from living donors who subsequently develop end-stage renal disease (ESRD) also have higher graft failure, suggesting the 2 donor kidneys share risk factors that could inform recipient outcomes. Given that donor ESRD is rare, an earlier and more common postdonation outcome could serve as a surrogate to individualize counseling and management for recipients. Hypertension is a frequent event before donor ESRD; thus, early postdonation hypertension might indicate higher risk of graft failure., Methods: We studied Scientific Registry of Transplant Recipients data to quantify the association between early postdonation hypertension and recipient graft failure using propensity score-weighted Cox proportional hazards regression. We also examined the association between postdonation systolic blood pressure and graft failure., Results: Of 37 901 recipients, 2.4% had a donor who developed hypertension within 2 years postdonation. Controlling for donor and recipient characteristics, recipients whose donors developed hypertension had no higher risk for graft failure (adjusted hazard ratio [aHR] 1.03, 95% confidence interval [CI] 0.85-1.25, P = 0.72). This was consistent among subgroups of recipients at higher risk for adverse outcomes due to hyperfiltration: African American recipients (aHR 1.10, 95% CI 0.70-1.73, P = 0.68) and those with ESRD caused by hypertension (aHR 1.10, 95% CI 0.65-1.85, P = 0.73) or diabetes (aHR 0.80, 95% CI 0.56-1.13, P = 0.20). However, graft failure was associated with postdonation systolic blood pressure (per 10 mm Hg, aHR 1.05, 95% CI 1.03-1.08, P < 0.001)., Conclusions: Although postdonation systolic blood pressure is associated with graft failure, the reported diagnosis of hypertension as determined by the requirement for blood pressure treatment early postdonation did not portend a higher risk of recipient graft failure in the same way as eventual postdonation ESRD.

Purpose of Review: Although the first successful kidney transplantation 65 years ago was performed with a living donor kidney, the number of living donor kidney transplantations has increased especially during the last 2 decades. The enlargement of living donor programs was made possible by new modes of living donation and by expansion of the living donor pool. At the same time, the long-term risks of kidney donation have been better delineated. In this review, the latest developments on these topics are summarized., Recent Findings: While the results of ABO-incompatible living kidney transplantation are superior to those of deceased donor transplantation, recent meta-analyses show a reduced patient and graft survival as compared with ABO compatible transplantation as well as increased risk of severe infection and bleeding. Kidney paired donation programs can be extended by including compatible couples and by advanced donation, although the latter raises ethical concerns. Living donors appear to have a higher risk of end-stage renal disease and this is especially true for obese donors and probably also for black donors with an APOL1 high-risk genotype. The importance of psychosocial outcomes after living kidney donation is increasingly recognized., Summary: Living donor kidney transplantation remains the optimal treatment option for patients with end-stage renal disease. To increase the donor pool, a well developed paired kidney donation program and sufficient reimbursement of costs associated with donation are essential ingredients. Other ways of expanding the donor pool, such as ABO-incompatible transplantation, use of higher risk donors, providing donors with financial incentives and advanced donation are associated with medical, ethical and logistical complications. There should be a careful selection and follow-up of living kidney donors with attention for medical consequences as well as for psychosocial outcomes.

Background: Alcoholic liver disease (ALD) accounts for 15%-30% of transplants performed in the United States and Europe; however, the data on living donor liver transplantation (LDLT) for ALD remain sparse. The purpose of this study was to examine the outcomes following LDLT for ALD using data from the adult-to-adult living donor liver transplantation (A2ALL) study, which represents the largest Western experience with adult-to-adult LDLT., Methods: A retrospective review of A2ALL data collected between 1998 and 2014 was performed. Patients were excluded if they received a deceased donor liver transplant. Demographic data, postoperative outcomes and complications, graft and patient survival, and predictors of graft and patient survival were assessed., Results: Of the 1065 patients who underwent LDLT during the study time period, 168 (15.8%) were transplanted for a diagnosis of ALD. Comparing patients who underwent transplant for ALD with those who were transplanted for other etiologies of liver disease, there was no significant difference in graft survival at 1 (88% versus 84%), 5 (76% versus 74%), or 10 years following transplant (55% versus 61%, P = 0.29). Similarly, there was no difference in patient survival at 1 (94% versus 91%), 5 (83% versus 79%), or 10 years following transplant (61% versus 66%, P = 0.32)., Conclusions: LDLT for ALD results in excellent 1-, 5-, and 10-year graft and patient survival. Patients with ALD and impaired renal function have a higher risk of graft loss and death. These findings support the notion that early LDLT for patients with ALD may help optimize outcomes.

Purpose of Review: In the United States, most of the liver allografts come from deceased donors, and our current liver recipient selection process is heavily centered on the ethical principle of utility to maximize the net benefit to the liver recipient community as a group rather than individuals due to the organ scarcity. Although living donor liver transplantation contributes less than 5% of total liver transplant in the United States, these living donor recipients are being subjected to the same selection process designed to benefit the group as a whole rather than the individuals. We would like to examine if these recipients who have living donors should be subjected to the same selection process., Recent Findings: There are several disease processes where liver transplantation is the only curative option, and recent studies have shown clear survival benefits with liver transplantation., Summary: For those who have living donors, different selection criteria based on their specific disease, not based on the principle of utilization should be used to evaluate their candidacy.

Background: The innovative pure laparoscopic living donor right hepatectomy (LLDRH) procedure for liver transplantation has never been fully compared to open living donor right hepatectomy (OLDRH). We aimed to compare the donor safety and graft results of pure LLDRH to those of OLDRH., Methods: From May 2013 to July 2017, 288 consecutive donors underwent either OLDRH (n = 197) or pure LLDRH (n = 91). After propensity score matching, 72 donors were included in each group. The primary outcome was postoperative complications during a 90-day follow-up period. Comprehensive complication index, duration of hospital stay, need for additional pain control, readmission, and donor outcomes were also compared., Results: The incidence of major complication during the 90-day follow-up was higher in the LLDRH group than the OLDRH group (6.6% vs 15.4%, P = 0.017) but was not statistically significant in propensity-matched analysis (11.1% vs 13.9%, odds ratio [OR], 1.29; 95% confidence interval [CI], 0.47-3.51; P = 0.62). A right hepatic duct <1 cm was independently associated with complication in the pure LLDRH group (odds ratio, 4.01; 95% confidence interval, 1.08-14.99; P = 0.04)., Conclusions: In the initial 91 pure LLDRH cases, incidence of major complication was higher than in the OLDRH group, but the difference was not significant in propensity-matched analysis. A right hepatic duct verified as <1 cm may be related to increased frequency of complications in pure LLDRH donors. Further analysis is needed.

Objective: In this study, we sought to assess likelihood of living donor kidney transplantation (LDKT) within a single-center kidney transplant waitlist, by race and sex, after implementation of an incompatible program., Summary Background Data: Disparities in access to LDKT exist among minority women and may be partially explained by antigen sensitization secondary to prior pregnancies, transplants, or blood transfusions, creating difficulty finding compatible matches. To address these and other obstacles, an incompatible LDKT program, incorporating desensitization and kidney paired donation, was created at our institution., Methods: A retrospective cohort study was performed among our kidney transplant waitlist candidates (n = 8895). Multivariable Cox regression was utilized, comparing likelihood of LDKT before (era 1: 01/2007-01/2013) and after (era 2: 01/2013-11/2018) implementation of the incompatible program. Candidates were stratified by race [white vs minority (nonwhite)], sex, and breadth of sensitization., Results: Program implementation resulted in the nation's longest single-center kidney chain, and likelihood of LDKT increased by 70% for whites [adjusted hazard ratio (aHR) 1.70; 95% confidence interval (CI), 1.46-1.99] and more than 100% for minorities (aHR 2.05; 95% CI, 1.60-2.62). Improvement in access to LDKT was greatest among sensitized minority women [calculated panel reactive antibody (cPRA) 11%-49%: aHR 4.79; 95% CI, 2.27-10.11; cPRA 50%-100%: aHR 4.09; 95% CI, 1.89-8.82]., Conclusions: Implementation of an incompatible program, and the resulting nation's longest single-center kidney chain, mitigated disparities in access to LDKT among minorities, specifically sensitized women. Extrapolation of this success on a national level may further serve these vulnerable populations.

Background: It has been suggested that deceased donor kidneys could be used to initiate chains of living donor kidney paired donation, but the potential gains of this practice need to be quantified and the ethical implications must be addressed before it can be implemented., Methods: The gain of implementing deceased donor-initiated chains was measured with an algorithm, using retrospective data on the pool of incompatible donor/recipient pairs, at a single center. The allocation rules for chain-ending kidneys and the characteristics and quality of the chain-initiating kidney are described., Results: The benefit quantification process showed that, with a pool of 69 kidneys from deceased donors and 16 pairs enrolled in the kidney paired donation program, it was possible to transplant 8 of 16 recipients (50%) over a period of 3 years. After obtaining the approval of the Veneto Regional Authority's Bioethical Committee and the revision of the Italian National Transplant Center's allocation policies, the first successful case was completed. For the recipient (male, aged 53 y), who entered the program for a chain-initiating kidney with a Kidney Donor Risk Index of 0.61 and a Kidney Donor Profile Index of 3%, the waiting time was 4 days. His willing donor (female, aged 53 y) with a Living Kidney Donor Profile Index of 2, donated 2 days later to a chain-ending recipient (male, aged 47 y) who had been on dialysis for 5 years., Conclusions: This is the first report of a successfully completed, deliberate deceased donor-initiated chain, which was made possible after a thorough assessment of the ethical issues and the impact of allocation policies. This article includes a preliminary efficacy assessment and describes the development of a dedicated algorithm.

Objective: The aim of this study was to compare outcomes between living donor liver transplant (LDLT) and deceased donor liver transplant (DDLT) at a single center to demonstrate the advantages of LDLT and provide justification for the increased utilization and application of this procedure., Summary of Background Data: LDLT comprises a very small percentage of all liver transplants performed in the United States, this despite its advantages and a shortage of the availability of deceased donor organs., Methods: A retrospective review of all adult LDLT (n = 245) and DDLT (n = 592) performed at a single center over 10 years (2009-2019), comparing survival outcomes by Kaplan-Meier analysis and comparing other measures of outcome such as recovery times, complications, costs, and resource utilization., Results: Patient survival outcomes were superior in LDLT recipients (3-year 86% vs 80%, P = 0.03). Other outcomes demonstrated shorter length of hospital stay (11 vs 13 days, P = 0.03), less likelihood of intraoperative blood transfusion (52% vs 78%, P < 0.01), and less likelihood of need for posttransplant dialysis (1.6% vs 7.4%, P < 0.01). Early reoperation and biliary/vascular complication rates were similar. Hospital costs related to the transplant were 29.5% lower for LDLT. Complications in living donors were acceptable with no early or late deaths, 3-month reoperation rate of 3.1%, and overall complication rate of 19.5%. Given its advantages, we have expanded LDLT-in 2018, LDLT comprised 53.6% of our transplants (national average 4.8%), and our transplant rate increased from 44.8 (rate per 100-person years) in 2015 to 87.5 in 2018., Conclusions: LDLT offers advantages over DDLT including superior outcomes and less resource utilization. The time has come to change the paradigm of how LDLT is utilized in this country.

Purpose of Review: With an increasing demand for donor organs, strategies to increase the number of available donor organs have become more focused. Compensating donors for donation is one strategy proposed to increase the availability of organs for transplant. This has been implemented in several systems internationally, but debate continues in the United States with respect to appropriate strategies. The National Organ Transplant Act (NOTA) currently prohibits the transfer of any human organ 'for valuable consideration' for transplantation, but allows for the removal of financial disincentives., Recent Findings: Several proposals currently exist for compensating patients for living donation. Recent data have focused on studying and creating mechanisms for reimbursement of costs incurred as part of the donation process, which is related to the removal of disincentives to living donation. Others have advocated for the provision of actual incentives to patients for the act of donating, in an attempt to further expand living donation. The current debate focuses on what measures can reasonably be taken to increase donation, and whether additional incentives will encourage more donation or reduce the motivation for altruistic donation., Summary: Currently, the transplant community broadly supports the removal of disincentives for living donors, including reimbursement of expenses for travel, housing and lost wages incurred during evaluation, surgery and after care. Others have advocated for financial incentives to further increase the number of donor organs available for transplant. Although the removal of disincentives is currently allowed under the existing legal structure of NOTA, providing financial incentives for living donation would require further evaluation of the economics, law, ethics and public readiness for a significant policy shift.

Few studies have investigated the risk of physiological sequelae in living kidney donors (KDs). We conducted a population-based cohort study using the National Health Insurance Research Database of Taiwan, which covers more than 99% of citizens.We comprehensively investigated the risk of medical disorders after kidney donation in living KDs using a maximum follow-up of 13 years. From January 1997 to December 2010, 1081 living KDs and 1082 age- and sex-matched non-KDs were eligible. Primary outcomes comprised end-stage renal disease, chronic kidney disease, stroke, cancer, acute myocardial infarction, acute renal failure (ARF), and diabetes.The adjusted hazard ratios (HRs) for developing ARF, diabetes, hyperlipidemia, hypertension, cancer, end-stage renal disease, acute myocardial infarction, and stroke were similar between the KD and non-KD cohorts (P > .05). Although differences in the adjusted HRs of ARF were nonsignificant, the cumulative incidence rate of ARF 13 years after donation was 7.48 per 1000 person-years in the KD cohort compared with 3.46 in the matched non-KD cohort. The incidence rate ratio for ARF between donors and nondonors significantly increased to 2.16 (95% confidence interval, 1.61-2.71).Living KDs experienced no significant health disorders following kidney donation but should be alert to the higher incidence rate of ARF.

Among living donor liver transplantation recipients, the impact of educational levels on survival has rarely explored. Thus, the purpose of study is to analyze the survival rate differences across educational levels among recipients who underwent living donor liver transplantation.We retrospectively analyzed 2007 adult recipients who underwent living donor liver transplantation in a single large center. The educational level was divided into three categories: middle school or lower, high school, and college or higher. The primary outcome was all-cause mortality after living donor liver transplantation. Stratified log-rank test and Cox proportional hazard model were employed for statistical analysis.The incidence rates of all-cause mortality were 23.85, 20.19, and 18.75 per 1000 person-year in recipients with middle school or lower, high school, and college or higher education groups, respectively. However, the gender-stratified log-rank test has not shown a statistically significant difference (P = .3107). In the unadjusted model, hazard ratio (HR) was 1.02 [95% confidence interval (CI) = 0.79-1.33] in high school and 1.23 (95% CI = 0.93-1.64) and in middle school or lower educational level, respectively; In the full adjusted model, the HR of high school was 0.98 (95% CI = 0.75-1.28) and the HR of middle school or lower was 1.01 (95% CI = 0.74-1.37).Although study population of this study is large, we could not find significant survival rate differences by the levels of education. Social selection and high compliance rate might contribute to this result.

Background: The rate of measured glomerular filtration rate (GFR) change in kidney donor years after donation has not been adequately addressed. Whether this change is accelerated in the setting of 1 kidney is also understudied., Methods: Two hundred fourteen randomly selected donors underwent serial GFR measurements of nonradioactive iohexol. Estimated GFR at each visit was calculated using the Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease study equations., Results: Glomerular filtration rate visits were 4.8 ± 1.3 years apart and the second occurring 16.9 ± 9.1 years after donation. Most (97.7%) were white, 60.8% female, and 78.5% were related to their recipient. Most, 84.6%, had a GFR of 60 mL/min per 1.73 m or higher, 14.0% had a GFR between 45 and 60 mL/min per 1.73 m, and 1.4% had a GFR less than 45 mL/min per 1.73 m. Between visits 1 and 2, 56.5% had a GFR decline, 36.0% increase, and in 7.5%, there was no change. Overall, GFR declined at a rate of -0.42 mL/min per 1.73 m per year. Of GFR estimating models, only Chronic Kidney Disease Epidemiology Collaboration-Creatinine equation produced a slope that was steeper than measured GFR., Conclusions: Nearly 2 decades postdonation GFR declined at a rate similar to that seen in the general population, and in one third, GFR continues to increase.

Background: The donation of multiple allografts from a single living donor is a rare practice, and the patient characteristics and outcomes associated with these procedures are not well described., Methods: Using the Scientific Registry of Transplant Recipients, we identified 101 living multiorgan donors and their 133 recipients., Results: The 49 sequential (donations during separate procedures) multiorgan donors provided grafts to 81 recipients: 21 kidney-then-liver, 15 liver-then-kidney, 5 lung-then-kidney, 3 liver-then-intestine, 3 kidney-then-pancreas, 1 lung-then-liver, and 1 pancreas-then-kidney. Of these donors, 38% donated 2 grafts to the same recipient and 15% donated 2 grafts as non-directed donors. Compared to recipients from first-time, single organ living donors, recipients from second-time living donors had similar graft and patient survival. The 52 simultaneous (multiple donations during one procedure) multiorgan donors provided 2 grafts to 1 recipient each: 48 kidney-pancreas and 4 liver-intestine. Donors had median of 13.4 years (interquartile range, 8.3-18.5 years) of follow-up. There was one reported death of a sequential donor (2.5 years after second donation). Few postdonation complications were reported over a median of 116 days (interquartile range, 0-295 days) of follow-up; however, routine living donor follow-up data were sparse. Recipients of kidneys from second-time living donors had similar graft (P = 0.2) and patient survival (P = 0.4) when compared with recipients from first-time living donors. Similarly, recipients of livers from second-time living donors had similar graft survival (P = 0.9) and patient survival (P = 0.7) when compared with recipients from first-time living donors., Conclusions: Careful documentation of outcomes is needed to ensure ethical practices in selection, informed consent, and postdonation care of this unique donor community.

Background: Posttransplant liver graft failure occurs most often in male recipients of livers from female donors. The respective role of donor sex itself and the size disparity in graft vessels/bile ducts according to donor sex are unclear. Thus, we aimed to evaluate the importance of donor sex with adjustment for anastomotic size disparity between female and male donor grafts., Methods: A total of 309 male patients without hepatic tumors who underwent living donor liver transplantation were analyzed (109 female donors and 200 male donors). The primary outcome was posttransplant graft failure (ie, retransplantation or death). Survival analysis was performed using the Cox model. Analyzed anastomosis-related factors comprised graft weight, number and size of hepatic vessels/bile ducts, and anastomosis techniques., Results: Graft failure probabilities at 1, 6, 12, 24, and 60 months posttransplantation were 9.1%, 19.5%, 20.2%, 23.0%, and 27.0%, respectively, with female donors and 2.0%, 5.5%, 8.1%, 10.1%, and 13.5% with male donors (hazards ratio [HR], 2.29; 95% confidence interval [CI], 1.35-3.88; P = 0.002). Multivariable analysis confirmed the significance of donor sex (HR, 2.30; 95% CI, 1.14-4.67; P = 0.021) after adjustment for anastomosis-related factors. All analyzed anastomosis-related factors showed no significant association with graft failure, although size of the graft hepatic artery showed marginal significance (HR, 0.50; 95% CI, 0.25-1.01; P = 0.053). The significance of donor sex was lost when donor was older than 36 to 40 years (age of poor ovarian reserve and the end of female fertility). Our institutional pediatric recipient cohort validated the inferiority of female-to-male donation., Conclusions: Donor sex appears to be an independent factor modulating graft failure risk in male liver transplant recipients.

Objective: African Americans and other minorities are known to face barriers to health care influencing their access to organ transplantation but it is not known whether these barriers exist among pediatric liver transplant waitlist candidates. We sought to determine whether outcomes on the waitlist (ie, mortality, deceased donor liver transplantation [DDLT], and living-donor liver transplantation [LDLT]) varied by race/ethnicity., Methods: National registry data were studied to estimate the race/ethnicity-specific risk of waitlist mortality, DDLT and LDLT in children (<18 years) waitlisted between March 2002 and March 2015., Results: There was no evidence of racial/ethnic disparities in waitlist mortality. Compared to Caucasians, LDLT varied by race/ethnicity, with only 6.7% African Americans and 10.3% Hispanic children receiving LDLT compared with 12.4% Caucasian, 13.3% Asian, and 9.4% mix/other children. In an adjusted Cox proportional hazards model, African Americans were half as likely as Caucasians to use LDLT (hazard ratio [HR]: 0.410.550.73) but had similar use of DDLT (HR: 0.981.061.16). In a model that considered mortality, DDLT, and LDLT as competing risks, African Americans had significantly reduced incidence of LDLT (subhazard ratio [sHR]: 0.410.560.75) compared to Caucasians, but increased use of DDLT (sHR: 1.061.161.26)., Conclusions: Compared to Caucasian children, African-American children are less likely to use LDLT but have higher rates of DDLT and similar survival on the waitlist. Additional research is necessary to understand the clinical and socioeconomic factors contributing to lower utilization of LDLT among African-American children awaiting transplantation.

The influence of the biological relationship between the donor and the recipient is rarely discussed in living donor liver transplantation (LDLT), although it is believed to be an important risk factor in other types of organ transplantations. A total of 272 consecutive patients undergoing adult to adult right lobe LDLT were retrospectively analyzed and stratified into a nonbiologically related (NBR) group (69 patients) and a biologically related (BR) group (203 patients). The preoperative data and postoperative outcomes of both recipients and donors were evaluated.More than two-thirds of the recipients had histories of HBV infection, and hepatocellular carcinoma (HCC) was the main reason for the patients undergoing LDLT in both groups. The percentage of female donors in the NBR group was more than the percentage in the BR group (P = 0.000). There were no differences between the groups in postoperative laboratory testing or daily immunosuppression dose, and the complication rates in both the recipient and donor surgeries showed no significant differences. For patients with benign diseases, the cumulative 1-, 3-, 5-, and 10-year survival rate were 92.9% in the 4 periods in the NBR group and 89.1%, 87.6%, 83.7%, and 83.7%, respectively, in BR group, while for the patients diagnosed as HCC, if patients exceeding the Milan criteria were involved, the 5-year survival rate was 41.2%, compared to 82% for patients within the Milan criteria, which was nearly the same as for those with the benign disease. In conclusion, our findings suggested that the biological relationship between the donor and the recipient in adult to adult LDLT was not associated with the short- and long-term outcomes of recipients diagnosed with benign liver diseases and early stage HCC. Moreover, the criteria for patients diagnosed with HCC to undergo LDLT should be restrictively selected., Competing Interests: The authors have no conflicts of interest to disclose.

Given the increased burden of end-stage renal disease (ESRD), renal outcomes of kidney donation by living donors are of particular interest. PubMed, ProQuest, MEDLINE, EMBASE, Chinese national knowledge infrastructure, and Wanfang databases were searched for clinical outcomes of living kidney donors (LKDs) including renal death, ESRD, proteinuria/albuminuria, and renal function after donation. We included 62 studies from 19 countries involving 114,783 kidney donors and nondonors to evaluate the renal consequences less than 6 months, 6 months to 5 years, 5 to 10 years, and 10 years onward after donation. The pooled data showed that uninephrectomy significantly decreased glomerular filtration rate and creatinine clearance rate in parallel with increased serum creatinine concentration (all P < 0.05). The drastic changes in renal function occurred within 6 months rather than 5 to 10 years after donation. Ten years and onward, rate of proteinuria/albuminuria increased gradually: microalbuminuria from 5.3% to 20.9%, proteinuria from 4.7% to 18.9%, and overt proteinuria from 2.4% to 5.7% (all P < 0.05). Prevalence of ESRD was 1.1%. All-cause mortality was 3.8% and all the renal deaths on average occurred 10 years postnephrectomy. LKDs might have aggravated glomerular filtration and creatinine clearance within 6 months after donation. Five years and onward, albuminuria, proteinuria, ESRD, and death might be the major concerns of LKDs. Long-term studies may clarify the survival time after donation., Competing Interests: The authors have no conflicts of interest to disclose.

Background: Enhancements in the national transplant law to prohibit commercial transplants in India have curbed the trade. Yet, the human rights abuse of human trafficking for organ removal (HTOR) continues in various transplant centers throughout India., Methods: Beginning in September 2010 until May 2012, in-depth interviews were conducted with 103 victims of HTOR in India in which victims described their experiences of a commercial kidney removal in compelling detail. Victims were located in Tamil Nadu, and reference is made to the broader study that included 50 additional victims in small towns and villages in West Bengal and Karnataka., Results: Fourteen cases (14%) in Tamil Nadu and an additional 20 cases (40%) from West Bengal and Karnataka occurred between 2009 to May 2012. The cases in Tamil Nadu ranged in age from 19 to 55 years, with an average age of 33 years in Erode and 36 years in Chennai. Fifty-seven percent of the victims in Erode are female, and 87% of the victims in Chennai are female. Twelve percent of the individuals were widowed or abandoned, 79% were married, and 91% were parents with an average of two kids. Of those interviewed, 28% had no formal education, 19% had some primary schooling, 22% had some secondary schooling, and no individuals reported schooling above high school. All victims interviewed lived in abject poverty with monthly income levels well below the national average. The majority of victims reported long lasting health, economic, social, and psychological consequences. No matter the reason expressed for an organ sale, all victims reported that they would not have agreed to the organ removal if their economic circumstances were not so dire. One hundred percent of the victims interviewed expressed that they need assistance to cope with these consequences., Conclusions: Human trafficking for an organ removal continues in private transplant centers throughout India, service to foreign patients is ongoing, and victims' consequences are long lasting. A rights-based response to HTOR that invokes a universal commitment to prevent, protect, and suppress its continued practice is recommended. The United Nations Trafficking Protocol is the key international instrument to address trafficking of persons, including for organ removal. India has signed the UN Trafficking Protocol and should ratify it to better address this form of human trafficking.

Background: Although U.S. transplantation programs must submit living-donor follow-up data through 2 years after donation, the submissions have high rates of incomplete or missing data. It is important to understand barriers programs face in collecting follow-up information., Methods: Two hundred thirty-one programs performing living kidney donor (LKD) and/or living liver donor (LLD) transplantation were contacted to complete a survey about program attitudes concerning donor follow-up, follow-up practices, and barriers to success., Results: Respondents representing 147 programs (111 with only LKD and 36 with both LKD and LLD) participated. Sixty-eight percent of LKD and 83% of LLD respondents said that achieving follow-up was a high priority. The majority agreed that donors should be followed at least 2 years (61% LKD programs and 73% LLD programs), and sizeable percentages (31% LKD and 37% LLD) endorsed 5 years of follow-up. However, approximately 40% of programs lost contact with more than 75% of their donors by 2 years after donation. Follow-up barriers included donors not wanting to return to the program (87%), out-of-date contact information (73%), and lack of program (54%) or donor (49%) reimbursement for follow-up costs. Whereas 92% of LKD and 96% of LLD programs inform potential donors about follow-up requirements, fewer (67% LKD and 78% LLD) develop plans with donors to achieve follow-up., Conclusions: Most respondents agree that donor follow-up is important, but they report difficulty achieving it. Improvements may occur if programs work with donors to develop plans to achieve follow-up, programmatic standards are set for completeness in follow-up data reporting, and sufficient staff resources are available to ensure ongoing post-donation contact.

Background: Patients after liver transplant have a high incidence of chronic kidney disease and end-stage renal disease (ESRD). We investigated kidney transplantation after liver transplantation using the Organ Procurement Transplant Network database., Methods: The Organ Procurement Transplant Network database was queried for patients who received kidney transplantation after previous liver transplantation. These patients were compared with patients who received primary kidney transplantation alone during the same time period., Results: Between 1997 and 2008, 157,086 primary kidney transplants were performed. Of these, 680 deceased donor kidney transplants and 410 living donor kidney transplants were performed in previous recipients of liver transplants. The number of kidney after liver transplants performed each year has increased from 37 per year to 124 per year in 2008. The time from liver transplant to kidney transplant increased from 8.2 to 9.0 years for living donor transplants and from 5.4 to 9.6 years for deceased donor. The 1, 3, and 5 year actuarial graft survival in both living donor kidney after liver transplant and deceased donor kidney after liver transplant are less than the kidney transplant alone patients. However, the death-censored graft survivals are equal. The patient survival is also less but is similar to what would be expected in liver transplant recipients who did not have ESRD. In 2008, kidney after liver transplantation represented 0.9% of the total kidney alone transplants performed in the United States., Conclusion: Kidney transplantation is an appropriate therapy for selected patients who develop ESRD after liver transplantation.

Background: Use of the Model for End-Stage Liver Disease (MELD) score has improved the efficiency of allocating deceased donor organs for liver transplant. However, its use may reduce access to deceased donor livers for patients with primary sclerosing cholangitis (PSC) due to the weighting of the MELD score variables. To overcome such barriers in the post-MELD era, clinicians might refer patients with PSC, relative to patients without PSC, for living donor transplants more frequently., Methods: To test this hypothesis, we examined patients in the United Network for Organ Sharing database from December 1, 1994, to May 31, 2009., Results: In multivariable models conditioned on transplant center, patients with PSC were significantly more likely to receive a living donor transplant in both the pre-MELD (odds ratio [OR]=2.75; 95% confidence interval [CI], 2.20-3.44) and post-MELD eras (OR=4.08; 95% CI, 3.45-4.82). There was a significant interaction between PSC and post-MELD era of transplantation (OR=1.48; 95% CI, 1.11-1.97), indicating that patients with PSC were more likely to receive living donor transplants at baseline relative to patients without PSC, and that this effect was magnified following the introduction of the MELD score., Conclusions: These findings raise the possibility that allocating livers on the basis of MELD score may have yielded the unintended consequence of increasing rates for living donor transplants for patients with PSC relative to patients with other forms of end-stage liver disease. Future research is needed to determine whether the practice of selectively transplanting patients with PSC with living donor transplants is associated with differences in clinical outcomes.

Prediction of kidney transplant outcome represents an important and clinically relevant problem. Although several prediction models have been proposed based on large, national collections of data, their utility at the local level (where local data distributions may differ from national data) remains unclear. We conducted a comparative analysis that modeled the outcome data of transplant recipients in the national US Renal Data System (USRDS) against a representative local transplant dataset at the University of Utah Health Sciences Center, a regional transplant center. The performance of an identical set of prediction models was evaluated on both national and local data to assess how well national models reflect local outcomes. Compared with the USRDS dataset, several key characteristics of the local dataset differed significantly (e.g., a much higher local graft survival rate; a much higher local percentage of white donors and recipients; and a much higher proportion of living donors). This was reflected in statistically significant differences in model performance. The area under the receiver operating characteristic curve values of the models predicting 1, 3, 5, 7, and 10-year graft survival on the USRDS data were 0.59, 0.63, 0.76, 0.91, and 0.97, respectively. In contrast, in the local dataset, these values were 0.54, 0.58, 0.58, 0.61, and 0.70, respectively. Prediction models trained on a national set of data from the USRDS performed better in the national dataset than in the local data. This might be due to the differences in the data characteristics between the two datasets, suggesting that the wholesale adoption of a prediction model developed on a large national dataset to guide local clinical practice should be done with caution.

Background: Little is known about the long-term outcomes of obese living kidney donors (OLKDs). We undertook this study to describe renal outcomes of OLKDs several years after donation., Methods: We invited 101 OLKDs for follow-up health evaluation., Results: Thirty-six subjects (35.6%) completed evaluation at 6.8±1.5 years postdonation. The mean estimated glomerular filtration rate (eGFR) using the abbreviated modification of diet in renal disease (MDRD) equation (MDRD-eGFR) at follow-up was 72.1±16.3 (range: 42-106) mL/min per 1.73 m, and 47.2% of subjects had an MDRD-eGFR of 30 to 59. The absolute decrease in MDRD-eGFR from the time of donation to follow-up was 27.2 ± 13.1 mL/min per 1.73 m (P<0.001 on paired t test), which represents a 29.2% drop in the serial MDRD-eGFRs. Seven subjects (19.4%) had microalbuminuria (30-300 μg/mg creatinine). Subjects with microabuminuria were more likely to have MDRD-eGFR of less than 60 mL/min per 1.73 m (P=0.021). Subjects whose body mass index was greater than or equal to 35 kg/m (n=14) were found to have an absolute decrement in MDRD-eGFR similar to those with body mass index less than 35 kg/m (31.5 ± 15.6 and 24.7 ± 11.0 mL/min/1.73 m, respectively; P=not significant). Fifteen (41.6%) were hypertensive at follow-up., Conclusions: On medium-term follow-up, a large proportion of OLKDs will have a MDRD-eGFR of less than 60 mL/min per 1.73 m, and the likelihood increases markedly among those who develop microalbuninuria. This raises concern for hyperfiltration injury. Furthermore, OLKDs experience a substantial incidence of hypertension. Caution is advised in selecting OLKDs pending further data on long-term outcomes.

Background: Renal grafts have demonstrated capacity to adapt to the recipient. The aim of this study was to assess the growth of renal grafts transplanted to children, during the first year posttransplant., Methods: We conducted a 1 year prospective study comparing the growth of renal grafts from children and adults donors transplanted in children, and correlated this growth with graft function. Two groups were studied: (a) group 1-32 children transplanted with pediatric deceased kidneys from donors younger than 16 years and (b) group 2-31 children transplanted with organs from adult living donors. Anthropometric assessment, sonographic measurement of the graft, and serum creatinine at 1 week, 1, 6, and 12 months posttransplantation were performed., Results: Children from group 1 presented an 18% increase in graft volume after the sixth month of transplant, whereas in group 2 grafts presented a 14% reduction in volume, mainly during the first month; the variation in renal diameters was not uniform. Children from group 1 presented a glomerular filtration rate (GFR) increase during the follow-up (46-102 mL/min/1.73 m). After 1 year, GFR and graft volume were similar. Growth of individuals from both groups was comparable., Conclusions: In the short term, pediatric kidneys raise volume and GFR, whereas adult kidneys slightly lower volume and GFR when transplanted in children. Taking our and other studies results into consideration, we can hypothesize that in addition to compensatory hypertrophy, pediatric grafts are likely capable of continued somatic growth.

Background: Living kidney transplant donors generally have a favorable renal functional outcome postuninephrectomy, but concern remains that a reduced glomerular filtration rate (GFR) postuninephrectomy might have harmful effects. This study examines the short-term (3 months) effect of donor nephrectomy on GFR and the occurrence of stage 3 chronic kidney disease (CKD) postuninephrectomy., Methods: The prevalence of stage 3 CKD (Kidney Disease Quality Outcome Initiative [GFR<60 mL/min/1.73 m]) was examined in 196 living donors by comparing preuninephrectomy and 3-month postuninephrectomy values of GFR using I-iothalamate GFR (iGFR), modification of diet in renal disease estimated GFR (eGFR), Cockcroft-Gault estimated creatinine clearance, and endogenous 24-hr creatinine clearance. The accuracy of GFR estimations for predicting iGFR was also studied., Results: The mean GFR before and after donation were iGFR, 105+/-18 and 68+/-13 mL/min/1.73 m; eGFR, 98+/-19 and 63+/-12 mL/min/1.73 m; Cockcroft-Gault estimated creatinine clearance, 125+/-33 and 85+/-22 mL/min/1.73 m, and endogenous 24-hr creatinine clearance, 133+/-38 and 86+/-24 mL/min/1.73 m, respectively. Stage 3 CKD was found postuninephrectomy in 53 donors (27%) by iGFR and in 73 donors (38%) by eGFR. The prevalence of stage 3 CKD was greater with older age. GFR estimation equations did not accurately predict iGFR, particularly postuninephrectomy., Conclusions: Stage 3 CKD is commonly observed after living kidney donation, particularly in older donors. The long-term impact of stage 3 CKD postuninephrectomy is poorly understood and may not have the same implications as stage 3 CKD in other conditions. eGFR is a poor predictor of true GFR in kidney donors.

Background: The number of living donor kidney transplantations increases steeply in Europeans, whereas the non-Europeans are dependent on deceased donor transplantations. We wondered whether a low attendance or a high decline of potential non-European donors could explain this difference., Methods: This retrospective study includes all 1059 potential living kidney donors who attended our pretransplant clinic between 2000 and 2007. Potential donors were divided according to eight countries of origin: African, Dutch Antillean, European, Indonesian, Moroccan, Surinamese, Turkish, and various countries. In addition to direct living donation, alternative living donation programs are operational in our center: kidney exchange, domino paired, ABO incompatible, and anonymous donation., Results: European donors predominated in both the potential (79%) and the actual donor populations (85%). Actual donors comprised 39% of non-European and 59% of the European potential donors (P<0.001). Participation in alternative donation programs is significantly less among non-European donors in comparison with European donors (3.6% vs. 12.6%, P<0.001). In all non-European populations, genetically related donors predominated, whereas genetically related and unrelated donors were equally represented in the European potential donor population (P<0.001). Partners were under-represented in all non-European populations (P<0.001). The attitude and behavior of non-Europeans with the longest duration of stay in the Netherlands were closest to that of the Europeans. The population with the shortest stay differed the most. This could possibly be attributed to integration., Conclusion: There are less non-European donors than expected based on the population composition. Living donor characteristics are different between Europeans and non-Europeans. The reasons for the difference deserve investigation.

Background: Traditional, cohort-based survival analysis approaches may provide outdated graft and patient survival estimates in times when clinical progress is rapid. Period analysis, a survival analysis method that uses left truncation and was shown to provide more up-to-date survival estimates than traditional, cohort-based methods in other medical fields, may improve the timeliness of survival monitoring in transplantation., Methods: Using United Network for Organ Sharing/Organ Procurement and Transplantation Network data, we evaluated, through a series of comparisons, how well most up-to-date 5-year survival estimates potentially derivable by two commonly used cohort-based methods and the period method would have been able to predict the later observed survival of corresponding most recent transplants in the dataset between 1992 to 1994 and 2001 to 2003., Results: In the analysis of overall survival, period analysis provided a best prediction for 93 of the 100 evaluated point estimates, whereas among 350 evaluated point estimates of age-specific survival, period analysis provided a best estimate on 254 occasions (72.6%), compared with 49 (14.0%) and 82 (23.4%) occasions for the cohort-based approaches. Mean average absolute differences between period estimates and the later observed survival were meaningfully lower than those obtained by traditional methods, indicating that period estimates may provide much better survival predictions for recently transplanted grafts and patients than estimates derivable at the same time by traditional survival analysis approaches., Conclusion: The timeliness of survival monitoring can be meaningfully improved by the application of period analysis. The use of period analysis for providing more up-to-date survival estimates in transplantation may be encouraged.

Purpose of Review: Partial renal ablation in laboratory animals leads initially to compensatory glomerular hyperfiltration and progressive, sclerotic kidney disease. In addition, modest declines in kidney function are associated with premature mortality in epidemiological studies. Hence, the long-term safety of living-kidney donation is an important issue. The purpose of this review was to examine existing research on outcomes among living-kidney transplant donors, with a focus on longer term outcomes., Recent Findings: Although studies with sibling controls are unavailable, the current evidence base suggests that kidney donors have mortality and end-stage renal disease risks that are equivalent to similar individuals in the general population. Although findings for albuminuria and hypertension vary between studies, risks may be acceptable if donors receive optimal follow-up and care. Parenthetically, viewed as an experimental model of kidney-function loss, the neutrality of outcomes among donors may have major implications for the population at large: the robust associations between modest declines in kidney function and mortality seen in the general population suggest a confounded relationship and finding these confounders could have major implications for future research directions and for public health., Summary: Long-term outcomes suggest that kidney donation is not a major threat to longevity.

Introduction: With the worldwide shortage of donors, extra lengths are ongoing to enlarge the donor pool. One means has been a greater use of "expanded criteria donor" (ECD) grafts. A major concern regarding ECD kidneys is poor long-term graft survival. The aims of this study were to determine whether ECD grafts, as defined by the United Network for Organ Sharing, had a negative impact on graft survival and to identify the principle donor and recipient factors that influenced graft survival in our patient cohort., Methods: We analyzed all deceased donor renal transplants in our unit from January 1995 to October 2005, in total 1,053 transplants., Results: ECD grafts (United Network for Organ Sharing criteria) demonstrated higher rates of delayed graft function and higher early mean creatinine levels. However, there was no significant difference in 5-year graft survival. Multivariate analysis of our patient group identified donor hypertension and ischemic heart disease (IHD) as independent predictors of poor graft survival. Recipient age was significant on univariate but not on multivariate analysis. However, although younger recipients maintained acceptable 5-year graft survival despite donor hypertension, IHD, or a combination of both, these factors significantly reduced graft survival in older recipients., Conclusion: Although ECD grafts had slightly worse function, 5-year survival was comparable with standard grafts in all recipients. Donor hypertension, IHD, or a combination of both significantly reduced graft survival in older recipients, not evident in younger patients. We discuss the possible factors for improved outcome with ECD grafts in our patients and the implications of our patient analysis.

Background: We assessed postoperative complication rates in living donor nephrectomies (LDN) during the last decade (1997-2008)., Methods: Postoperative complications were classified by the Clavien grading system. We defined Clavien grade more than or equal to 3 as major complications. A total of 1022 LDNs performed during the period 1997-2008 were included., Results: Median age at donation was 47.7 years (range 18.4-78.9), and mean body mass index was 25.4 (SD 3.2). There was no peri- or postoperative mortality. Laparoscopic nephrectomy was performed in 244 (23.9%) donors. Three of these needed surgical conversion. A total of 30 major (2.9%) and 184 (18%) minor complications were registered. There was a higher frequency of major complications in the laparoscopic group (4.1% vs. 2.6%), but the difference was not statistically significant. Twenty-three donors underwent early re-operations. Wound infection developed in 3.7% of donors. Increased risk was associated with body mass index more than 25 (OR 4.03; 95% CI 1.80, 9.04) and smoking (OR 4.38; 95% CI 2.30, 9.96). Significant perioperative bleeding occurred in 1.6%. There were seven cases of renal artery laceration. Increased risk for a combined endpoint of intraoperative incidents, major complications and significant bleeding were seen in relation to laparoscopic surgery (OR 2.63; 95% CI 1.33, 5.19)., Conclusion: The risk of major complications related to LDN is low, but do represent a potential hazard to the donor. The special nature of LDN and the constantly evolving operative technique requires vigilant surveillance, by the use of national or supranational registries/databases.

Background: We recently reported a randomized study in renal transplant patients (RTP) receiving tacrolimus, mycophenolate mofetil, and prednisone in which patients who had early protocol biopsies (PBx) derived no benefit compared with controls (no PBx) at 6 months, likely due to the low prevalence of subclinical rejection. We report on the follow-up of these patients to 24 months at which time a repeat PBx and tests of renal function were performed., Methods: Of the 240 RTP randomized, 22 were excluded for a protocol violation. Approximately 75% of the remaining 218 (111 PBx and 107 controls) completed the study., Results: At 24 months, graft function was excellent with a mean creatinine clearance of approximately 74 mL/min and negligible proteinuria; however, the prevalence of interstitial fibrosis and tubular atrophy (IF/TA)-ci + ct more than or equal to 2-increased from approximately 3% at baseline to up to 40% to 50%. By logistic regression analysis, the only independent positive correlate of IF/TA was transplantation with a deceased donor. However, by post hoc analysis, use of angiotensin-II-converting enzyme inhibitors or angiotensin II receptor blockers was negatively correlated with both the prevalence of IF/TA at 24 months and its progression between 6 and 24 months in RTP that had paired biopsies., Conclusions: A regimen of tacrolimus, mycophenolate mofetil, and prednisone results in excellent renal function at 24 months posttransplant but with a progressive increase in IF/TA. A potential inhibitory effect of angiotensin-II-converting enzyme inhibitor/angiotensin II receptor blockers on IF/TA is suggested that requires confirmation in a randomized study.

Background: Although it is known that the incidence of fracture events is increased in renal transplantation recipients, the timing and the factors associated with risk of fractures are less well understood. The objective of this study was to estimate the time to fracture in renal transplantation recipients and to determine whether risk was associated with patient and transplantation characteristics., Methods: Using the U. S. Renal Data System, we retrospectively studied 68,814 patients, who underwent renal transplantation between 1988 and 1998. Fractures were identified from International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes in billing data. Time to first fracture was modeled during the first 5 years posttransplant using the Kaplan-Meier method and Cox proportional hazards models., Results: Of the patients who underwent transplantation, 22.5% developed a fracture within 5 years. Woman (hazard ratio [HR] 1.36, P<0.0001), patients older than 45 years of age (HR 1.14, P<0.0001) especially older than 65 years (HR 1.69, P<0.0001), and whites (HR 1.28, P<0.0001) were at increased risk of a fracture. Additionally, receipt of a deceased donor kidney (HR 1.30, P<0.0001), increased human leukocyte antigen mismatches (HR 1.09, P<0.014), diabetes (HR 1.88, P<0.0001), pretransplant dialysis (HR 1.08, P<0.0001), and an aggressive induction immunosuppression regimen (HR 1.14, P<0.0001) all significantly increased risk of fracture events during the first 5 years., Conclusions: In addition to patient demographic features, donor factors, including suboptimal organ quality and the need for more intense immunosuppression, were associated with an increased risk of fractures during the first 5 years after a renal transplant.

Background: Short-term outcomes using steroid-free immunosuppression after renal transplantation have been promising. No studies have examined the incidence of and reasons for steroid-avoidance protocol failures., Methods: We present a single-center analysis of steroid-free immunosuppression failures among 129 pediatric renal transplant recipients with mean follow-up of 5 years. We analyzed causes for failure and examined reasons for conversion to steroid-based therapy. We compared actual patient and allograft survival and allograft function in the cohort of patients who required conversion to steroid-based immunosuppression with that of the cohort maintaining steroid-free immunosuppression., Results: A total of 13.2% (17/129) of patients failed steroid-free immunosuppression. Actual patient survival was equivalent in the two cohorts, 96.4% for the cohort maintaining steroid-free immunosuppression and 94.1% for those requiring conversion. Actual allograft survival was lower in patients requiring conversion to a steroid-based protocol, 76.5% vs. 95.5% (P=0.004). Estimated glomerular filtration rates 12-months and 24-months posttransplant were greater in patients maintaining steroid-free immunosuppression (P=0.003). Most patients (52.9%, 9/17) who broke the steroid-free protocol did so because of refractory acute rejection. The second most common reason was recurrence of glomerulonephritis (GN; 35.3%, 6/17)., Conclusion: The failure rate of steroid-free immunosuppression among selective pediatric patients undergoing renal transplantation is low. Patients maintaining steroid-free immunosuppression have better allograft survival and function than those requiring conversion to steroid-based therapy. The most common reasons for failure of steroid-free immunosuppression are recalcitrant or recurrent allograft rejection and recurrent GN; the role of conversion to steroid-based immunosuppression after episodes of acute rejection and recurrent GN requires additional analysis.

Background: Renal transplantation (RTx) in the geriatric population (age >65 years) accounts for 14% of all RTx performed nationally in 2007., Methods: We reviewed 3297 RTx recipients from our database over a 15-year period to evaluate recipient and donor age, date of transplant and graft loss, cause of graft loss, and cold ischemic time in the geriatric population., Results: Since 1991, we have performed 468 living donor RTx (LDRTx) and deceased donor RTx (DDRTx) in patients more than 65 years: 280 (65-69 years), 128 (70-74 years), and 60 (>75 years). Geriatric recipients of DDRTx demonstrated 83.0%, 74.1%, and 64.1% uncensored graft survival at 1, 3, and 5 years, respectively. Interestingly, these rates were similar compared with DDRTx in adults (18-64 years, P=0.49). Geriatric recipients of LDRTx demonstrated 1-year, 3-year, and 5-year graft survival rates of 94.3%, 88.8%, and 72.3%, respectively. Although better than geriatric DDRTx recipients, these results were not equal to the success of adult LDRTx recipients, potentially because of poorer graft survival in LDRTx recipients more than 75 years (P=0.004). Death-censored graft survivals were similar between adult and geriatric recipients of LDRTx (P=0.28). Graft loss secondary to death was twice as great in geriatric versus adult recipients (P<0.01)., Conclusions: DDRTx geriatric recipients of each group showed similar uncensored graft survivals to adult DDRTx recipients. LDRTx had better outcomes than DDRTx in geriatric recipients. Death-censored outcomes were similar between adult and geriatric LDRTx recipients. These data support the equivalent outcomes of RTx in appropriately selected geriatric recipients.

Background: After human leukocyte antigen (HLA) antibody-incompatible transplantation, donor specific and third party HLA antibodies may be found, and their levels fall in a donor-specific manner during the first month. However, these changes have not been previously described in detail., Methods: Donor-specific HLA antibody (DSA) and third-party HLA antibody (TPA) levels were measured using the microbead method in 44 presensitized patients who had renal transplantation., Results: DSA+TPA fell in the first 4 days after transplantation, and greater falls in DSA indicated absorption by the graft. This occurred for class I (57.8% fall compared with 20.2% for TPA, P<0.0005), HLA DR (63.0% vs. 24.3%, P<0.0004), and for HLA DP/DQ/DRB3-4 (34% vs. 17.5%, P=0.014). Peak DSA levels occurred at a mean of 13 days posttransplant, and they were higher than pretreatment in 25 (57%) patients and lower in 19 (43%) patients (P=ns). The risk of rejection was associated with peak DSA levels; 15 of 25 (60%) patients with DSA at median fluorescence intensity (MFI) more than 7000U experienced rejection, compared with 4 of 7 (57%) patients with peak DSA MFI 2000 to 7000U, and 2 of 12 (17%) patients with peak DSA MFI less than 2000U (P<0.02). DSA levels subsequently fell in a donor specific manner compared to TPA., Conclusion: DSA levels may change markedly in the first month after antibody incompatible transplantation, and the risk of rejection was associated with higher pretreatment and peak levels.