ETHICAL CONSIDERATIONS ON KIDNEY TRANSPLANTATION FROM LIVING DONORS

Kidney transplantation from living donors is widely performed all over the world. Living nephrectomy for transplantation has no direct advantage for the donor other than increased self-esteem, but at least remains an extremely safe procedure, with a worldwide overall mortality rate of 0.03%. This theoretical risk to the donor seems to be justified by the socioeconomic advantages and increased quality of life of the recipient, especially in selected cases, such as pediatric patients, when living donor kidney transplantation can be performed in a preuremic phase, avoiding the psychological and physical stress of dialysis, which in children is not well tolerated and cannot prevent retarded growth. According to the Ethical Council of the Transplantation Society, commercialism must be prevented, not only for ethical but also medical reasons. The risks are too high not only for the donors, but also for the recipients, as a consequence of poor donor screening and evaluation with consequent transmission of human immunodeficiency virus or other infectious agents, as well as inappropriate medical and surgical management of donors and also of recipients, who are often discharged too early. Most public or private insurance companies are considering kidney donation a safe procedure without long-term impairment and, therefore, do not increase the premium, whereas recipient insurance of course should cover hospital fees for the donors. “Rewarded gifting” or other financial incentives to compensate for the inconvenience and loss of income related to the donation are not advisable, at least in our opinion. Our center does not perform anonymous living organ donation or “cross-over” transplantation. Kidney transplantation from living donors performed successfully for the first time in 1954 by Murray is now considered a good clinical solution complementary to cadaver (CD) kidney transplantation to increase the donor pool. With the increasing availability of dialysis, many centers subsequently discouraged transplantation from living donors, however, the introduction of Cyclosporine (CsA) with a significant improvement in the results of cadaver kidney transplantation together with a dramatic growth in the number of patients on the waiting list, due to an inadequate supply of cadaver kidneys, prompted expansion of the criteria for acceptable living donors. The validity of this procedure is based on many ethical and clinical considerations including the results that in most reports are better than with cadaver donor kidney transplantation, the free willingness of the donor, and the limited amount of risks for his or her health. Both conventional and laparoscopic living donor nephrectomy are safe procedures with a worldwide overall mortality of 0.03%.1 However, at least 4 kidney donors world world have developed end-stage renal failure and have undergone kidney transplantation.2 Our center activated a living related donor (LRD) kidney transplantation program in 1967 and a living unrelated donor (LURD) kidney transplantation program in 1968, performing 62 kidney transplantation including LURDs. In the CsA era, our group did the first living donor kidney transplantation in 1982 and the first LURD transplantation Europe in 1983.