With hundreds of thousands of people around the world waiting for an organ donation to give themselves a fighting opportunity at a second chance at life, one doctor says it's at this time of year that people should consider giving the ultimate gift -- organ donation -- that for many people could result in the saving of a life.
According to Transplant Nephrologist Dr. Adrian Sawyer, whose specialty is studying the kidney and treating kidney disease, there is a need for organ donation, and even more specifically kidney donation
Referencing the United States Renal Data System Report during his recent Doctors Hospital Distinguished Lecture Series, Dr. Sawyer said the total number of transplants from 1997-2011 was in the region of 170,000 persons -- a drop in the bucket considering the number of people that need transplants -- high among them are people of the African Diaspora who Dr. Sawyer said historically have been reluctant to donate organs, that is up until 2007, despite the fact that people of African ancestry make up 12 percent of the population and account for 28 to 30 percent of patients with kidney failure on dialysis, or who require a transplant.
During his lecture, Dr. Sawyer also spoke to the increase in recent years of organ donations from living persons, so-much-so that in developed countries like the United States, United Kingdom and Spain in particular, he said one in three-to-five donations of a kidney is from a living donor rather than a deceased donor.
And in a world where there are three kidney replacement treatment options --Hemodialysis, which the 2013 United States Renal Data System Report that came out last month says the cost per patient reached $87,000 per year to maintain one patient; Peritoneal dialysis which is somewhere in the region of almost $70,000 per year; and the best form of kidney replacement -- kidney transplant which varies anywhere from $18,000 to $30,000 a year which obviously makes transplantation a winner. It has also pushed the increase for organs to be donated.
The total number of transplants between 1997 and 2011 was in the region 170,000, according to Dr. Sawyer.
"In developed countries such as the United States, United Kingdom, Spain in particular, one on three to five donations of a kidney is done from a living donor, rather than a deceased donor."
One reason for the increase in living donors according to the doctor was the 2008 World Health Organization paper that was published to provide orderly, ethical and acceptable framework for organ transplantation, related to 11 principles that people should address when dealing with organ donations.
Organ donation principles
Organs may be removed from deceased persons for transplantation if consent is legally obtained, and there is no reason to believe the deceased objected to removal. Physicians determining death of a potential donor should have no affiliation with the transplant process at all. Donations from a deceased person should be developed to a maximum therapeutic level and living donors to any extent should be genetically, legally, or emotionally related to the recipient. The altruistic donor is someone who is not related legally, emotionally or genetically, but has decided for purposes of showing his or her belief in the goodness of man that if you have two kidneys that are working perfectly, you should give the gift of life.
In the principles, no tissue should be removed from a living minor or any legally incompetent person (to prevent abuse, and to prevent the issue of organ trafficking on the vulnerable and the disadvantaged). Organ donations should be without financial reward to the donor, next of kin, or any third party. And health professionals and insurers should not be party to organs obtained by coercion (indirect or direct force), or improper payments. All health professionals and facilities should be prohibited from receiving any payment exceeding the justifiable fee for the service rendered.
In the principles, organ allocation should be guided by clinical criteria, ethical norms, and the process must be transparent and externally justified. The doctor said the system should be high quality and safe, and that the procedure should be efficacious, and that long term income and outcomes need to be assessed for donor and recipient.
The principles also state that the organization and execution of transplantation activity must be transparent, and open to scrutiny. They also state that medical professionals must ensure that personal anonymity and privacy of donors and recipients are always protected. (There may be instances where people may be willing to indicate they have had an organ donated, or that they have been a successful recipient, but it has to be something done on a voluntary basis.)
Organs that can be transplanted
Organs that can be transplanted or given include the kidneys, the heart, which has to be given after death; a portion of your lung or one lung; you can now donate portions of your liver for kidney transplantation, even though the majority of those organs are taken from what Dr. Sawyer says they call deceased persons.
Kidney donations can be had from deceased donors -- people who have had either strokes, head trauma or have irreversible brain damage, but who in fact still have certain organs that are functioning. It was this group of people who according to the doctor used to be the bulk of donors for a long time.
Living donors consist of two groups -- living related and living unrelated. He also said that another group that has come about in relationship to the shortage of organs, called extended criteria donors who are people who are not dead, but may have a high blood pressure, and may have protein in their urine. He said these are people would not ordinarily be considered for donation, but over the years since the age at which people can donate or people would accept organs has increased, medical professionals can in fact use the organs that aren't ideal to transplant into older people who have a shorter life expectancy and who, he said, can do very well.
Paired kidney donation, he said, has evolved in the last five years, again as a strategy to try and improve the number of organs available for transplant. Organization for Procurement and Transplantation Network in the United States dealing with kidney transplants.
In 2013, Dr. Sawyer said of all donor types they had just over 12,500; almost 8,500 deceased donors; living donors, he said, almost reached 50 percent.
"This is evidence of the fact that living donation is certainly taking off. To compare in 2000 the same figures, 13,500; deceased donors made up almost two-thirds and live donors made up just less than one-third."
Wait listing
The time that people spend waiting for a well-matched kidney so that they can get their kidney transplant can take years. Dr. Sawyer said in 2013, all of the people awaiting transplants amounted to 121,000, with 98,000 of those persons awaiting kidney transplants. People awaiting pancreas and
kidney/pancreas transplants totaled just over 3,000 with people waiting on liver transplants numbering 15,000, and people awaiting heart transplants just over 3,500.
He said the total number of transplants performed from January to September 2013 in the United States was 21,000 with deceased donors numbering 17,000 and living donors at 4,500.
Since they started doing transplants at Doctors Hospital in 2006, Dr. Sawyer said they received a total of 37 referrals up to 2013. Out of all the referrals for patients who required a transplant, and 28 potential donors, they only managed to get one successful in that seven-year span.
According to the transplant nephrologist, one of thing that has happened in the last 15 years is that chances of a patient's body rejecting a transplant have declined with the advent of new drugs. He said rejection has fallen dramatically from a high 50 percent to less than 15 percent, which he said is the norm for transplant programs today.
African ancestry take note
Dr. Sawyer said when considering a transplant, doctors and transplant teams have to consider that the donation must be voluntary first, not coerced -- physical, emotional or otherwise. He said they have to take into account that no harm should come to the donor, either in the short tem or the long term. And that there should be evidence of benefit to the recipient, more importantly, the recipient's ability to comply with immunosuppressive therapy is important. The side effects of long-term steroid besides an increase in appetite, a patient's cheeks getting fat, developing diabetes, and even getting ulcers, they don't heal as well, and may develop hypertension.
He said developed protocols have allowed Caucasians to be able to reduce the dosage of steroids significantly, or even eliminate them after six months to a year. But he said they are the only people transplanted in that group who seem to do well, and that people of African ancestry are a very high-risk group.
"Steroid avoidance, or steroid reduction protocols in people of African ancestry are a no-no," he said.
According to Dr. Sawyer, the recurrence of the primary disease also has to be considered. He said one of the biggest diseases for which people will get kidney failure is diabetes and high blood pressure, both of which have a genetic component. And that when considering a transplant you don't want to take kidneys from younger people (in their 20s') who are in the prime of life and who may be at risk for disease and kidney failure in the long term.
Challenges
In the challenges associated with kidney transplantation, Dr. Sawyer said the first thing people should do is to ensure that they are educated on the subject.
"There have been studies now to show that for 20 - 30 years on, in a well-organized transplant program, certainly as far as kidney donors are concerned, the outcomes for donors are slightly better in terms of quality of life, kidney function, satisfaction and longevity, than for age-matched controls in the general population who are not donors. There is an abundance of evidence now to show that once you have gone through a careful screening program the risk of one of the concerns you may have is what will happen with my kidney function with only one kidney.
"Autopsy studies indicate that in approximately one in 1,000, to one in 1,500 in the general population are born with only one kidney. We only find out about it if, for some reason, we have to do studies to image their kidneys, so yes we have two kidneys, nearly all of us, but we can live with one, we can live a normal life with one," he said.
The transplant nephrologist said other issues that have to be taken into account are cultural and religious acceptance as there are countries where the issue of disturbing a body after death is taboo.
When considering organ donation, in particular kidney donation, Dr. Sawyer said all tests and studies to find a match, except for the angiogram, has to be borne out of pocket.
"Unfortunately, insurance companies do not pay for this. Insurance companies will only kick in if we have one recipient and they have five potential donors. If after the tissue typing and assessment, you find one the best matched donor, if you have insurance, they will kick in only for that. All the people who have gone and done all these tests are out of pocket."
Giving the gift of life by becoming an organ donor during the month of December would coincide with a number of historic transplant -- the first successful kidney transplant was undertaken in Boston on December 23, 1954, and locally Doctors Hospital did its first kidney transplant at the Shirley Street and Collins Avenue 15-16 years ago on December 5, according to Dr. Sawyer.
"Organ donation is the ultimate gift that you can give a healthy person, to someone who has a failing organ," he said. "Most of us have only one brain, and one heart, the Creator in his wisdom decided to give us two kidneys -- so that means they're important."

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