*3.3.1. Older donors*

potential to increase the potential donor pool comprises non-hard beating cadaver kidneys

Situations requiring edge biopsy All people with normal renal function regardless of age (graft biopsy in donors over 60 years) Diabetic donors with normal renal function and without severe proteinuria All hypertensive donors with normal renal function All hypotensive donors Infected donors excluding viral hepatitis, HIV, Jakob-Creutzfeldt disease, viral encephalitis, malaria, disseminated TB CMV + RPR Positive urine cultures without pyelonephritis Bacteremic donors Donors with abnormal renal function Donors at high risk for infection (but negative on high sensitive tests) Donors with a history of malignancy disease-free for two years Skin tumors without metastases, excluding melanoma Primary CNS tumors without VP shunt

Non heart beating donors where widely used before the definition of brain death was accepted. They remain the major source of cadaver donors in countries such as Japan and Mexico, where brain death was recognized officially only recently and where social acceptance it is still limited [82]. Non heart beating donors yield about 5% of all cadaveric kidneys transplanted in USA. Use of non-heart beating cadaver donor kidneys has increased in last years. The one year survival of graft from non-heart beating donors was 83% and for brain death donors was 86%. Early function was not as good: 48% of recipient of non-heart beating donor kidneys required dialysis in the first week after transplantation compared to 22% of the recipients of kidneys from brain death donors. Primary non-function was slightly increased also (4% versus 1%). The serum creatinine level at discharge from hospital was higher in the first group. At one year follow-up, the serum creatinine levels for the two groups was, in fact, similar (1.9 mg/dL versus 1.8 mg/dL). When traumatic death were analyzed separately, the one year survival of non heart beating donors kidneys was 89% compared with 70% one year survival for non-traumatic death. Not all programs have found the same results from non-heart beating donors, but the finding of more frequent delayed function and need for dialysis has been universal. The potential for increasing the donor supply from non-heart beating donors has been estimated

and kidneys from older donor.

156 Current Issues and Future Direction in Kidney Transplantation

Adapted from [65]

**Table 5.** Expanded criteria for cadaveric donors

to be as high as 40% [83].

Already, older donors are a major source of cadaveric donation. Some doctors found out an inferior outcome from transplants from cadaveric donors over 55 years of age. Not only did a higher percentage of recipients of such kidneys required dialysis but one year serum creatinine level was higher than that from recipient of transplants from cadaveric donors aged 5 to 55 years and the estimated halve life of the kidney was 5.8 +/- 0.3 years compared to 11+/- 0.3 years. Other analysis have found similar results but suggests that the adverse effects of the donor ages affect only certain subgroups particularly black recipients.

#### *3.3.2. Hypertension*

Recipients of kidneys from donors with hypertension were more likely to have anuria and to require dialysis immediately after transplantation. Their serum creatinine level was significant higher at one year than that of recipients of kidneys from donors who were not hypertensive and the predictive graft survival was shorter (halve life of 7.7 +/- 0.5 years versus 10.7 +/- 0.3 years). Graft survival was better with 1 to 5 years of hypertension compared to 6 or more years of hypertension. The difference in serum creatinine and predicted graft survival between kidneys from diabetic and non-diabetic donors was of borderline statistical significance. Serum creatinine at one year was 1.8 +/- 0.8 mg/dL in recipient of kidneys from diabetic donors compared with 1.6 +/- 0.8 mg/dL in recipients of kidney from non-diabetic donors. Predicted halve life in this graft was 8.4 +/- 1.5 years compared with 10.1 +/- 0.3 years.

#### **3.4. Strategies for increasing organ donation**

In developing new strategies for increasing kidney available for transplantation we would do well to remember that from its beginning organ transplantation has relied on public good will and support. When public opposition exists, we sometimes avoid using approaches that we find ethically acceptable. Because we really don't know what ideas or practices will strengthen public support for all organ donation the introduction of new practices should be undertaken as pilot projects.

The public already accept living donors who were not considered 50 years ago such unrelated living donors and spouses, which are now widely excepted. Once we accept the donors autonomy and remind ourselves that the risk to the donor is not related to his relationship to the recipient, we will be able to accept the wide arrange and greater number of emotionally related donors. We need to understand that the altruistic donor, although unusual, is not pathologic. The altruistic donor can be considered an emotionally related donor who is emotionally related to all mankind. Thus, this approach to this type of donor is not to keep a registry of willing donors and their HLA types. The altruistic donor is not waiting for the right HLA type but for the right story. The acceptance of donor autonomy would allow for accepting donors with increased risk, but will require careful follow-up thus an increased risk of complications can be recognized.
