The history of kidney donation?

How altruistic kidney donation has grown in the UK – and where it is going in the future

Altruistic kidney donation from living donors is an uncommon but growing practice in the UK. The number of people willing to give the gift of life to someone who is not only unrelated to them by blood or marriage but a complete stranger more than quadrupled from six in 2007/08 to 34 in 2011/12 and 76 in 2012/13. At first only around 10 donations a year were expected but the figures have increased every year and are expected to go on rising.

It’s often said that altruistic donation became legal for the first time in 2006. In fact, although it is not known to have happened before then, there was nothing in the law to stop living donors giving their kidneys to anyone they chose, including a stranger, long before that – as the first legislation covering living donation was not passed until 1989. The Human Organ Transplants Act 1989 was rushed through Parliament in response to a “kidneys for sale” scandal in which impoverished men from Turkey were recruited to Britain to provide kidneys for paying patients. The organisation that regulates doctors in the UK, the General Medical Council, brought proceedings against three doctors, including one of the leading transplant surgeons of the day. One doctor was struck off, and the other two had conditions placed on their practice.

The 1989 Act made it a criminal offence to transplant an organ if the donor and recipient could not be proved to be genetically related, unless the donation was approved by a new body, the Unrelated Live Transplant Regulatory Authority (ULTRA). ULTRA counselled potential donors who wanted to give a kidney to a husband, wife, partner, close friend or sibling to whom they could not prove, by tissue typing, to be related, to make sure they were giving fully informed consent. ULTRA received some requests to allow altruistic donations from strangers, but in the wake of the kidney scandal Government ministers were opposed to the move, and the requests were rejected.

In 2004 new legislation, the Human Tissue Act, was passed in response to yet another scandal: the retention of dead children’s organs by pathologists at Alder Hey Hospital, Liverpool, and other hospitals without their parents’ knowledge or consent. This Act, which came into force in September 2006, set up a new authority, the Human Tissue Authority (HTA), to regulate all uses of human tissue, including organ transplantation. By then, in the light of experience in the United States and in response to pressure from surgeons and others working in the transplant field, it was decided that altruistic donations to strangers should be allowed.

The HTA must approve all organ transplantations involving living donors, whether or not they are related to the recipient. All donors are assessed by an independent assessor, to make sure the donor understands what is involved, is not under any pressure to donate and is giving consent freely and voluntarily. “Good Samaritan” donations – so-called non-directed altruistic donations, where the donor does not choose the recipient – are then considered for approval by a panel of HTA members.

Keith Rigg, a transplant surgeon at Nottingham University Hospitals NHS Trust, sits on the panels that consider applications from people who want to give a kidney to a stranger. He says that there are more men than women donors and that they tend to be middle aged or older – the average age of those giving an altruistic donation is 52, but there is a wide range of people from some in their 20s to some in their 70s. “They sometimes feel they’ve had to jump through a lot of hoops in order to be able to do this. It’s something they have thought through very carefully and they’ve discussed with their families. They’re very giving people.”

Altruistic donations are allowed in a number of countries, including the United States, Canada, Australia, the Netherlands and Spain.

In some countries, the altruistic donor has been linked to what is known as a “paired/pooled” donation scheme.

Paired/pooled donation schemes – how they work

When a living kidney donor and recipient are incompatible or mismatched with each other, it may be possible for them to be matched with another donor and recipient pair in the same situation and for the donor kidneys to be exchanged or swapped between the pairs. This means that each recipient receives a kidney from someone unknown, and the donors, likewise, donate to a recipient who is not known to them. When two pairs are involved like this, it is called a paired donation, and with more than two pairs it is called pooled donation. The benefit of this type of donation is that each recipient receives a living donor transplant that they would not otherwise have had.

Paired and pooled diagram

From January 2012, altruistic donors in the UK will be able choose to donate into the paired/pooled scheme instead of directly to the national transplant waiting list, creating “altruistic donor chains”. The donated kidney will be matched to a recipient in the paired/pooled scheme and, in turn, the donor registered with that recipient donates to another recipient, and so on. The chain ends when the last donor donates to a recipient on the national transplant waiting list. The minimum number of transplantations achieved from a single altruistic donation is two.

Every altruistic donor will be asked whether they are willing to donate into the paired/pooled scheme to create a chain, but they can opt out if they wish and instead donate directly to the national transplant waiting list.

Altruistic donor chains have already been carried out in other countries around the world, such as the United States, Korea and Japan.

Surgeons in Spain carried out that country’s first kidney transplantation chain in April 2011, involving two married couples and a patient who was on the waiting list for a kidney. The altruistic donor whose gift ended up giving life to three people who needed kidneys was a priest (www.bmj.com/content/342/bmj.d2798.full. For the full story, you will require a subscription to the journal or will need to pay)

For more details about how the national living donor kidney sharing schemes work, including non-directed altruistic donation, paired/pooled donation and altruistic donor chains, go to the NHS Blood and Transplant website (www.organdonation.nhs.uk)

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