Division of Nephrology, Department of Medicine, Shiraz Medical School, Shiraz, Iran
Correspondence and offprint requests to: P. Khajehdehi MD, Associate Professor of Medicine, House 53, Lane 10-Jangali, Mirza-Kouchak-Khan-Jangali Highway, Shiraz, 71959, Iran.
Abstract
Background. Persistent differences between social classes and genders exist in the quality of medical care due to disparities in need and access.
Methods. 149 haemodialysis (HD) patients including 114 renal transplant candidates, and their proposed live donors were interviewed and followed for 4 years. Differences in need and access were analysed among the living non-related compared to related renal transplant according to social status, age and gender of recipients and donors. Also the motive for organ-donation as well as the recipient's survival was compared between living non-related and related renal transplantation.
Results. The proportion of females among renal transplant candidates was significantly lower than among HD-patients. Females were significantly less likely to be recipients, but more likely to be donors of renal allografts, particularly if they were unemployed. Initially all of the living non-related donors claimed to have altruistic motives for organ-donation but gift rewarding, drug abuse, unemployment, and economical deadlock, urgent need of money were significantly frequent than among living related donors. The donation process lasted significantly longer in females and in living non-related donors and there was a trend for higher mortality in recipient of living non-related grafts. Almost all of the living non-related donors disappeared after organ-donation without subsequent follow-up.
Conclusions. Females are transplanted less frequently, but donate kidneys more frequently than males in living non-related transplantation programmes. There is an excess of vulnerable people among living non-related donors.
Keywords: end-stage renal disease; ethics; gender; haemodialysis; living related and non-related renal transplant; social status
Introduction
Kidney transplantation has become a worldwide practice, steadily increasing the demand for renal allograft, and causing a profound kidney shortage globally [13]. In some countries living organ donation has been the main source of kidney supply [47]. As the number of patients waiting for renal transplant continues to rise, the arguments against paying for live donated kidney bear re-examination [1,810]. On the other hand, the miracle of survival thus achieved by purchasing a human kidney, entails a whole series of complex and highly controversial ethical issues, especially an increasing disparity between need and access partly related to the recipients' social status, age and gender or race [1,718]. In addition, the motives for organ donation among living non-related donors compared to related ones have not been studied before; and hence, its effect on the donation process and recipient survival is not known. Thus, the following study was carried out to answer two questions:
Material and methods
Over a 4 year period, all consecutive newly admitted patients requiring regular-HD were studied who had no contraindication for renal transplantation, i.e. malignancy, active infections, advanced liver and lung or heart diseases. There were 149 HD-patients (83 men and 66 women) including 114 renal transplant candidates (80 men and 34 women), undergoing 23 sessions of HD weekly in the main teaching hospitals of the Shiraz University of Medical Sciences. HD patients were aged 31.7±7.4 years (range, 1556 years) and transplant candidates 30±8.3 years (range, 1850 years). All HD patients, transplant candidates and their donors were interviewed, separately and confidentially and were followed for 4 years. Living non-related renal transplant was considered only if HD patient had no genetically or emotionally related donor.
Statistical analysis
The data obtained were analysed by a special package for social science (SPSS) computer software program, using non-paired Student's t test, Chi-square test and Fisher exact test, whenever appropriate.
Results
The characteristics of 149 HD patients and 114 renal transplant candidates are compared in Table 1. Social status and age did not differ significantly between HD patients and transplant candidates, but the proportion of females amongst transplant candidates was less. Table 2
compares 114 living renal transplant candidates and 78 patients who were actually transplanted during the study (4 years) according to gender, showing that females were transplanted significantly less than males particularly if unemployed. Nine patients expired before transplantation was possible. Table 3
compares the living non-related and related donors according to gender. All donors belonged to the low or middle socioeconomic class. Neither social class nor age were significantly different between living related and non-related donors. The proportion of unemployed females was significantly higher among living non-related than related donors. All of the living non-related donors claimed to have altruistic motives for organ donation initially, but on further questioning all of them admitted receiving rewarding gifts in an amount enough to support a middle class type of life for 23 years in this country. Almost all (87%) of the living non-related donors were in an economical deadlock, needing money urgently for the following reasons: 10 unemployment (all drug abusers); 6 debt; 6 illness of first degree relative; 5 bankruptcy. Drug abuse was significantly more common among the living non-related than related donors. It took significantly longer until donation was implemented for living non-related than related renal transplant. There was also a trend for higher mortality in the recipients of the former. Ten out of 21 (48%) living non-related donors disappeared before organ donation. In females it took significantly (P<0.005) longer, i.e. 14.2±6.9 months (mean±SD) than in males, i.e. 19.1±6.2 months until they were transplanted. Twenty out of 21 non-related donors disappeared after organ-donation without a subsequent medical follow-up, and the remaining one only attended his first follow-up visit. Of 114 transplant candidates 105 cases had suitable donors among their first degree relatives, but only 47 of them donated a kidney. The 58 individuals refusing organ donation were afraid to lose their body integrity, and to become ill; disabled or sterile.
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To deal with kidney shortage it has been proposed to use living donors for organ donations [410]. At the same time serious ethical arguments have been raised concerning inevitable competition for human organs, increasing the gap between need and access for renal transplant depending on the recipients' social status, age and gender. It has been argued that the policy of using living non-related donor might adversely influence access to renal allograft for vulnerable people. Also poor individuals who have no other way to obtain money may serve as non-related donors especially in those countries where living organ donation has become the main source of kidney supply [47]. The impact of recipients' unemployment on the accessibility of renal allograft is not known. In this study we found that the proportion of unemployed females was significantly lower amongst transplant candidates than HD patients.
Only one communication reported that women are more likely to donate, but less likely to receive a kidney compared to men in a living related renal transplant programme [18] and this is confirmed by our analysis. In addition, we showed that women are more likely to be donors but less likely to be recipients of renal allograft compared with men in a living non-related renal transplant programme. It has been reported that older patients are less likely to be transplanted than younger ones [19], but we failed to find significant difference between the age of living related and non-related renal allograft recipients or the age of HD-patients and transplant candidates, indicating that age was not an important factor for renal transplant accessibility. To the best of our knowledge there has been no study comparing the motives between living non-related versus related renal transplant donors. Living non-related kidney donation was commonly prompted by economical motives. Live non-related donors, are generally vulnerable people who also receive no proper medical attention after organ donation. In Iran renal transplantation is in part funded by the National Charity Supportive Organizations for Kidney Disease. Nevertheless, in spite of preventive measures, vulnerable people are apparently more likely to be donors but less likely to be recipients in the living non-related renal transplant programmes. Thus, it seems appropriate to discourage living non-related but to encourage living related organ donation, unless the optimal solution of cadaver renal allograft is available. Misconceptions about consequences of kidney donation were common among first degree relatives of transplant candidates in this study. Mass educational programmes are appropriate to overcome such misconceptions and to increase the opportunity for organ donation without harming the rights of the patients.
References