Kidney Transplantation: A New Zealand Perspective
Tony Stephens
This article has come about in response to a request to The Nathaniel Centre for information about the processes and ethical issues surrounding kidney transplantation. When we approached the Donor Liaison Coordinator in the Renal Department at Capital and Coast DHB for updated information about kidney donation, he agreed to provide the following piece which describes the practices involved. There are currently about 700 people in New Zealand on waiting lists for a kidney transplant.
Organ transplantation is a life-saving and life-enhancing therapy for many people. In New Zealand the heart, heart valves, lungs, liver, pancreas, kidneys, corneas and skin can all be transplanted.1
While most donated organs come from deceased people, live donors can give one of their kidneys or part of their liver to someone in need.
A transplant kidney allows the recipient to lead a relatively normal life. While they must take anti-rejection medications for the rest of their life, this is easier to fit into normal life than dialysis.
In New Zealand over 91 percent of kidney transplants are working after one year with over 82 percent still working five years after surgery.2 Some transplants have lasted for over 30 years.
Deceased Organ Donation
In some countries - including New Zealand - a person or family must make a conscious decision to be an organ donor after death. This can be done by stating ‘donor’ on our driver’s license but, most importantly, by informing our families of our wishes. This approach is known as ‘opt-in’.
If you are in a non-survivable condition in an Intensive Care Unit (ICU) your family will be asked to consider giving permission for organ donation after death. If you want to be an organ donor, your family is much more likely to agree if they know in advance. Therefore, it is essential that you inform your family of your wishes to be an organ donor or not.
An ‘opt-out’ system is the opposite; a person and family must make a conscious decision not to be an organ donor. In the absence of a decision to opt-out it is assumed they have given consent to be an organ donor. In such cases, family members are also assumed to have given consent for organs to be removed from their loved one. An individual or family may not feel completely comfortable about being a donor but may feel that the pressure of society to donate compels them to be a donor.
Intensive Care
Over recent years, in an attempt to improve donation rates in New Zealand, there has been a focus on training ICU doctors and nurses to better identify potential donors and then sensitively raise the question with family members.
Unfortunately, some people mistakenly believe a patient may be treated less well in ICU because of the focus on their organs rather than their recovery. This is not true.
One of the most important issues addressed by ICU staff during family discussions is that the care of the patient will not be compromised, whether organ donation has been agreed or not.
The ICU and transplant teams are separate entities. The ICU team focuses on treating the patient, and someone who is going to donate organs after death is treated the same as anyone else with all possible steps taken to improve their condition.
While the transplant team is informed when there may be a potential donor dying in the near future, this team is not involved with the patient’s care while they are still alive. The transplant team performs its roles with deep respect, sensitivity and gratitude to the person and their family.
The doctors of potential recipients are also not involved in the care of someone dying in ICU, and are only informed of a potential organ donation late in the process. They do not go to the ICU to talk with family members or to influence the care and treatment the patient is receiving.
Sometimes families decline organ donation and often face criticism from the media. While it’s easy to criticize, we must remember that the family is in shock with their loved one dying in front of them. To then be faced with the decision to have organs removed can be overwhelming.
However, if the family knows that their loved one wishes to be a donor, it may be easier for them to agree to the organ donation. Conversely, if the family knows the person does not want to be an organ donor, they can express this clearly to the ICU staff who will respect and honour this wish.
Live Donation
A healthy person can donate a kidney to someone in need. Live donors are usually members of the recipient’s family, although friends are also often donors. Donors can also offer a kidney in an anonymous (non-directed) manner. In this case the best matching recipient from the waiting list is allocated the kidney from the non-directed donor.
Live donors go through an extremely vigorous testing process to help ensure they will be fit and healthy for the operation and for the rest of their lives. This testing process takes place over many months and involves many appointments with nurses, doctors, surgeons and psychologists. A live donor can withdraw from the process at any stage with the support of the renal team. Equally, at any stage they may be found unsuitable due to a health condition or concern about their future with one kidney.
There are risks involved in being a live kidney donor – risks associated with the surgery as well as a slightly higher chance of developing renal failure (due to having only one kidney). There is also a higher chance of developing high blood pressure later in life and the consequences this can have on the donor’s health and life expectancy. A younger donor will have a longer life ahead of them for possible complications to develop.3
In New Zealand, the minimum age to be an organ donor is 18. While all potential donors are asked why they want to donate, extra care is taken with young donors - an 18 year-old would be asked at each stage if this is what they really want to do and would undergo a psychological assessment to help determine their motivations and their mental state.
Due to the long-term risks of kidney donation, anyone with diabetes or hypertension is ruled out of being a donor. Other factors ruling out live kidney donation are obesity and major psychiatric issues.
Kidney donors are monitored by the renal service or their GP for the rest of their life to help ensure they stay healthy.
At times a live anonymous donor will specify that they would like to donate their kidney to a child, or a particular person (a celebrity for example) or to someone ‘who has looked after themselves.’ This is not an option as non-directed kidneys are allocated purely on a tissue-typing test. This test identifies the person on the waiting list who best matches the donor. This person is offered the kidney and, if they agree, a surgery date is arranged. If the recipient does not agree, the next person on the waiting list with the closest tissue match is offered the kidney.
Ranking by tissue-typing gives the donor kidney the best chance of working and of not being rejected by the recipient.
Safeguarding the Interests of live donors
The interests of the donor are safeguarded throughout the live kidney donation process. They have a different doctor to the recipient, enabling each doctor to focus on their particular patient without the possible conflict of interest, or pressure to help one over the other.
As the donor is seen by many health professionals throughout the process, there are many stages at which these professionals can determine whether organ donation is the right thing for a particular donor.. The healthcare team can also determine if the donor is being pressured, in which case a strategy can be formed to decline the donor in a way that keeps them safe from any possible family repercussions.
Coming forward as a potential live donor takes a great deal of courage. To go through surgery for no physical benefit is very brave. Potential donors do sometimes feel pressure to donate, not necessarily from their family but from within themselves. A person may feel they need to donate a kidney to their loved one, but also feel the need to look after their own family.
Overcoming these conflicting feelings is very difficult, and our advice for someone in this situation would be to not donate. Being a kidney donor requires single-minded determination and focus. If there is too much going on in the donor’s life it is likely to be too much for them to cope with.
Throughout the process, staff maintain the privacy of the donors’ information. At times a recipient will ask about how ‘their donor’ is getting on. Due to confidentiality reasons we cannot give information about the donor to the recipient. If a recipient wants information about the donor they will need to ask the donor.
Buying and Selling Organs
In some countries (such as India and Sri Lanka) some people sell their kidneys as a source of income. Invariably, these donors sell a kidney out of financial desperation and post-surgery are often treated poorly by the transplanting hospital.4 In New Zealand it is illegal to buy or sell organs for transplant. Nevertheless, this option is sometimes raised by people. In such cases, they are actively discouraged from going overseas to receive a kidney transplant. This is to try and reduce the demand in the organ market and to provide protection for donors who are driven by desperate circumstances to sell.5
Conclusion
Kidney transplantation is part of the wider treatment of kidney disease and offers a recipient the best chance of a better health outcome.
Kidney transplantation relies on brave and noble people to be donors – either after dying or as a live donor. Donors and their families are motivated by a strong desire to help someone in need.
For live donors, the desire to help someone and to improve the life of the recipient outweighs the short and long-term risks to their own health. Families of deceased donors often gain some comfort from the knowledge that the death of their loved one has given life to other people.
Tony Stephens is a Registered Nurse and works as Donor Liaison Coordinator in the Renal Department at Capital and Coast DHB.
Endnotes
- http://www.donor.co.nz/facts-and-myths/faqs/
- http://www.donor.co.nz/facts-and-myths/statistics/
- Reese, P, Boudville, N, Garg, A. (2015). Living kidney donation: outcomes, ethics and uncertainty. The Lancet. Vol 385, May 16: 2003-13
- Matas, A. (2012). Incentives for organ donation: proposed standards for an internationally acceptable system. American Journal of Transplantation. Vol 12(2): 306-12.
- http://www.declarationofistanbul.org/