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To the editor: The editorial comment1 on the Guirado et al article2 states that kidney transplant from living donors has obvious advantages over kidney transplant from cadaveric donors. In addition, given the relative scarcity of cadaveric donors, it is suggested that it would be convenient to increase the number of kidney transplants from living donors It is argued that the limited number of transplants from living donors is due to ignorance of this procedure by professionals and patient relatives, and that the fact that this possibility is not offered by physicians or not suggested by patients and relatives «reflects in a more or less obvious way the fear of nephrectomy in healthy people».
Sr. Director: En el comentario editorial1, sobre el artículo de Guirado y cols.2, se afirma que el trasplante renal de vivo ofrece evidentes ventajas frente al de cadáver. Y, dada la relativa escasez de donantes cadáver, se sugiere que sería conveniente un aumento de los trasplantes renales de vivo. Se argumenta que el limitado número de trasplantes realizados de vivo obedece al desconocimiento de este procedimiento por parte de profesionales y familiares de los enfermos, y que no ofertar esta posibilidad por parte del médico o de no plantearla por parte de los pacientes y familiares ¿refleja de manera más o menos aparente el miedo a la nefrectomía en una persona sana¿.
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To the editor: The editorial comment1 on the Guirado et al article2 states that kidney transplant from living donors has obvious advantages over kidney transplant from cadaveric donors. In addition, given the relative scarcity of cadaveric donors, it is suggested that it would be convenient to increase the number of kidney transplants from living donors It is argued that the limited number of transplants from living donors is due to ignorance of this procedure by professionals and patient relatives, and that the fact that this possibility is not offered by physicians or not suggested by patients and relatives «reflects in a more or less obvious way the fear of nephrectomy in healthy people».
However, the article2 explains that the better results achieved with kidney transplant from living donors stem from the statistical approach of the study, rather than the intrinsic kidney characteristics. Differences in patient and graft survival in univariate studies disappear when studies with a greater statistical power, multivariate, or with a control group of selected patients are conducted.3 That is, the assumed advantages inherent to living donors, such as shorter cold ischemia time, preemptive immunosuppression, absence of the consequences of donor¿s cerebral death, etc. do not appear to provide for better results with this type of donor.
By contrast, the influence of other factors, such as age, sex, body surface area, and HLA system compatibility between donor and receptor and waiting time on dialysis on transplant outcome is known. A shorter time on dialysis is the only advantage that use of a living instead of a cadaveric donor for transplant may offer. It should therefore be considered that acceptance of a living donor to obtain the beneficial effect of shortening the time on replacement therapy may be counteracted by the presence of incompatibilities in the other factors.
On the other hand, increases in the number of cadaveric donors are made possible by reduction of family refusals and promotion of extraction in non-beating heart donors. The excellent activity of Hospital Clínico in Madrid in this field should be extended to other extracting hospitals.4
With regard to the potential iatrogenics of kidney removal in donors, while no conclusive studies are available, most authors advise against use of nonoptimal donors because of the potential long-term implications.5
In conclusion, I think that an indiscriminate increase in kidney transplants from living donors with the single purpose of increasing the number of transplants should not be considered. Each potential transplant pair should be studied to decide whether or not transplant is recommended, and mid-term studies should be started on the potential implications
of donor nephrectomy.
However, the article2 explains that the better results achieved with kidney transplant from living donors stem from the statistical approach of the study, rather than the intrinsic kidney characteristics. Differences in patient and graft survival in univariate studies disappear when studies with a greater statistical power, multivariate, or with a control group of selected patients are conducted.3 That is, the assumed advantages inherent to living donors, such as shorter cold ischemia time, preemptive immunosuppression, absence of the consequences of donor¿s cerebral death, etc. do not appear to provide for better results with this type of donor.
By contrast, the influence of other factors, such as age, sex, body surface area, and HLA system compatibility between donor and receptor and waiting time on dialysis on transplant outcome is known. A shorter time on dialysis is the only advantage that use of a living instead of a cadaveric donor for transplant may offer. It should therefore be considered that acceptance of a living donor to obtain the beneficial effect of shortening the time on replacement therapy may be counteracted by the presence of incompatibilities in the other factors.
On the other hand, increases in the number of cadaveric donors are made possible by reduction of family refusals and promotion of extraction in non-beating heart donors. The excellent activity of Hospital Clínico in Madrid in this field should be extended to other extracting hospitals.4
With regard to the potential iatrogenics of kidney removal in donors, while no conclusive studies are available, most authors advise against use of nonoptimal donors because of the potential long-term implications.5
In conclusion, I think that an indiscriminate increase in kidney transplants from living donors with the single purpose of increasing the number of transplants should not be considered. Each potential transplant pair should be studied to decide whether or not transplant is recommended, and mid-term studies should be started on the potential implications
of donor nephrectomy.
Bibliography
[1]
Domínguez-Gil B, Pascual J. El trasplante renal de donante vivo en España: una gran oportunidad. Nefrología 2008; 28: 143-7. [Pubmed]
[2]
Guirado L, Vela E, Clèries M, Díaz JM, Facundo C, García-Maset R, Registro de enfermos renales de Cataluña. ¿Por qué el trasplante renal de donante vivo da mejores resultados que el trasplante renal de donante cadáver? Nefrología 2008; 28: 159-67. [Pubmed]
[3]
Solà R, Vela E, Cleries M, Guirado Ll, Diaz JM, Facundo C, Deulofeu R. Living donor kidney transplantation in Catalonia: comparison with cadaveric kidney donors. Transplant Proc 2007; 39: 2208-9. [Pubmed]
