*2.8.1.1. Incentives for organ donation*

The issue of public incentives to enhance donation is more than just complex but mainly sensitive. From a philosophical point of view, the body is a part of our personality, thus in respect with human dignity it would be wrong to use parts of our body as means only [26]. On the other hand, one may assert that everyone is the rightful owner of his person supporting the idea that the self can decide over its body like any kind of property [27].

Most frequently, the background attitude of general population is to reject incentives for donation but there might be circumstances under which attitudes may change [28]. For instance, when the process became transparent: the amount of compensations are specified or there might be some ethical reasons to do so. The main risk is exploitation of those severe impoverished on a black market [29].

The valuable exchange of organs is prohibited worldwide, yet there exists national law or regulations which allows incentives for deceased or living donation [30]. Such incentives including financial reimbursement, health care-related reimbursement or other recognition for living donors or deceased donors' families have been widely debated [31].

Donor medal of honor. Organ procurement organizations must have ceremonies which recognize and appreciate organ donation. A donor medal of honor enacted by a top official of the country expresses the appreciation and gratitude on behalf of the whole community to the living donors and even to the families of the deceased donor [32, 33].

Medical leave for organ donation. Currently organ donors risk loss of wages or even loss of employment because the time away from the work that is required for donation [34,35]. In many countries there are legislations that provide a 30 day medical leave for all employees who donate an organ for transplantation [36]. However, no one should have to incur a personal expense for donating an organ. Many national organizations are doing an effort to encourage hospitals with transplantation services to provide paid medical leave for employees who become organ donors. Even if legislation emphasizing that enrichment should not be the reason for the donation, paid medical leave has to be available to a larger number of wouldbe donors [37].

donorship, the same prohibition against the payment donor should be applied to organ

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Legal issues. Initially, most countries limited traditional transplantation to genetically of strong emotionally related pairs. With extend of paired kidney donation, such limitations were removed to allow both altruistic non-directed donation and paired donation. Although, any exchange in paired donation represent in fact a transaction between parts, it do not involve financial values. It is advisable that such a issue should be explicitly addressed by the legal

Allocation algorithm. Grafts allocation in paired kidney donation is one of the domain who largely benefits from theories derived from economics regarding stable allocation and the practice of market design [40]. The main goal is to maximize the number of matched pairs. Any such program should overcome the disadvantage of O recipients by increasing the likelihood to receive a compatible graft. The risk of a positive cross-match with a from the donor pool might be assessed by considering the HLA antibody profile of the recipients and the HLA profile of the donors [41, 42]. When done on a national scale, such a matching should include distance between transplant centers, matching the virusologic profile of the recipient and donor, donor's age and size. Recipients from such pairs will be suspended from the waiting list until either they will be transplanted or a incompatibility test will reveal that the exchange is not possible. List paired donation may increase the rate of transplants by expanding the donor pool. In such an exchange, an incompatible donor who will donate to a recipient from the waiting list while his recipient will receive a high priority for the allocation for a deceased donor kidney [43, 44]. There are several concerns regarding ethical and legal issues. Such a transplant is designed to give an alternative to O blood type recipients with a non-O incom‐ patible donor. The immediate consequence is the transplantation of a non-O blood group recipient from the waiting list and the addition of a O blood group recipient. This way, there

will be an increased pressure over the O blood group recipients [43, 44].

with a living donor available but incompatible, may overcome this issue.

Matching algorithms. Different matching algorithms were designed to maximize the number of recipients with an incompatible living donor will undergo renal transplantation. After an initial experience with two pairs, the number of pairs involved in a paired kidney transplan‐ tation increases to three, four and even more and the procedure gain worldwide acceptance. Involving of more than two pairs increases the chances to get a renal transplant but in order to avoid the withdrawal risk requires six or more operations to be done at the same time. Designed for O blood group recipients, exchanging of an incompatible kidney for a preferential position on the waiting list increases the recipient's chances for a renal transplantation but decreases the chances of other O blood group recipients from the waiting list [45-48]. This situation creates ethic dilemmas. Generalizing such list exchanges to any blood group recipient

Altruistic donation or non-directed donation is more ethical and legal challenging. It is difficult to believe and understand that a good Samaritan really exists and even when exists, national law framework should allow transplantation from unrelated living donor. Altruistic donors may be allocated to a waiting list or to initiate an open chain of paired transplantations [46,49].

exchanges.

framework of every country.

Ensuring access to organs for previous donors. As you have seen up to now, the majority of living donors are doing well after donation. However, it has been established that at 10 years after donation, under 5% of those who donated the kidney developed ESRD; this donors are being placed on waiting list for cadaver organs [38]. Despite the additional allocation priority points, these donors have to wait for a cadaveric kidney, some of them for a long period of time. The health and well being of living donor should be monitored in a follow-up register in order to document medical problems associated with donation that occur over ensuing years [22]. The need for a transplant in a previous kidney donor should be considered a high priority in the allocation of the organs.

Donor insurance. The fact that there are being cases in which a kidney donor died immediately after donation or needed a kidney transplant at a later date, serves as a reminder that a nephrectomy (any kind of nephrectomy) is not a risk free procedure. A survey at some centers of transplantation show that at least two kidney donors had died from perioperative compli‐ cations after a kidney donation and some of them had a persistent complication [39].

As a consequence, it should be enacted national plans to provide life and disability ensures for all living donors including a mechanism to ensure that they do not incur catastrophic medical expenses as a result of a donation.

#### *2.8.1.2. Organ exchanges*

Since the report of Rapaport which introduced the concept of paired kidney exchange as a method to enhance the number of living donors, these techniques have been applied in several countries with lower cadaver donation rates like Mexico, South Korea, Japan, and Europe (Holland and Romania).

Many persons who wished to donate an organ to a spouse or another family member where unable to help them due to incompatible blood type or other immunological barriers (positive cross-match). A program of paired kidney exchange addresses this problem by permitting an exchange of organs from two living donors [34] or from one living donor to one deceased donor. In the later approach, recently introduced in New England and Holland, a living donor incompatible with his intending recipient, donates an organ to a compatible patient on the waiting list for cadaveric organs in exchange for a priority allocation of a cadaveric organ to the donor's intended recipient. Thus, two transplantations are performed in circumstances that otherwise had permitted neither. Because such exchange could open the door to a paid donorship, the same prohibition against the payment donor should be applied to organ exchanges.

Medical leave for organ donation. Currently organ donors risk loss of wages or even loss of employment because the time away from the work that is required for donation [34,35]. In many countries there are legislations that provide a 30 day medical leave for all employees who donate an organ for transplantation [36]. However, no one should have to incur a personal expense for donating an organ. Many national organizations are doing an effort to encourage hospitals with transplantation services to provide paid medical leave for employees who become organ donors. Even if legislation emphasizing that enrichment should not be the reason for the donation, paid medical leave has to be available to a larger number of would-

Ensuring access to organs for previous donors. As you have seen up to now, the majority of living donors are doing well after donation. However, it has been established that at 10 years after donation, under 5% of those who donated the kidney developed ESRD; this donors are being placed on waiting list for cadaver organs [38]. Despite the additional allocation priority points, these donors have to wait for a cadaveric kidney, some of them for a long period of time. The health and well being of living donor should be monitored in a follow-up register in order to document medical problems associated with donation that occur over ensuing years [22]. The need for a transplant in a previous kidney donor should be considered a high priority

Donor insurance. The fact that there are being cases in which a kidney donor died immediately after donation or needed a kidney transplant at a later date, serves as a reminder that a nephrectomy (any kind of nephrectomy) is not a risk free procedure. A survey at some centers of transplantation show that at least two kidney donors had died from perioperative compli‐

As a consequence, it should be enacted national plans to provide life and disability ensures for all living donors including a mechanism to ensure that they do not incur catastrophic medical

Since the report of Rapaport which introduced the concept of paired kidney exchange as a method to enhance the number of living donors, these techniques have been applied in several countries with lower cadaver donation rates like Mexico, South Korea, Japan, and Europe

Many persons who wished to donate an organ to a spouse or another family member where unable to help them due to incompatible blood type or other immunological barriers (positive cross-match). A program of paired kidney exchange addresses this problem by permitting an exchange of organs from two living donors [34] or from one living donor to one deceased donor. In the later approach, recently introduced in New England and Holland, a living donor incompatible with his intending recipient, donates an organ to a compatible patient on the waiting list for cadaveric organs in exchange for a priority allocation of a cadaveric organ to the donor's intended recipient. Thus, two transplantations are performed in circumstances that otherwise had permitted neither. Because such exchange could open the door to a paid

cations after a kidney donation and some of them had a persistent complication [39].

be donors [37].

in the allocation of the organs.

144 Current Issues and Future Direction in Kidney Transplantation

expenses as a result of a donation.

*2.8.1.2. Organ exchanges*

(Holland and Romania).

Legal issues. Initially, most countries limited traditional transplantation to genetically of strong emotionally related pairs. With extend of paired kidney donation, such limitations were removed to allow both altruistic non-directed donation and paired donation. Although, any exchange in paired donation represent in fact a transaction between parts, it do not involve financial values. It is advisable that such a issue should be explicitly addressed by the legal framework of every country.

Allocation algorithm. Grafts allocation in paired kidney donation is one of the domain who largely benefits from theories derived from economics regarding stable allocation and the practice of market design [40]. The main goal is to maximize the number of matched pairs. Any such program should overcome the disadvantage of O recipients by increasing the likelihood to receive a compatible graft. The risk of a positive cross-match with a from the donor pool might be assessed by considering the HLA antibody profile of the recipients and the HLA profile of the donors [41, 42]. When done on a national scale, such a matching should include distance between transplant centers, matching the virusologic profile of the recipient and donor, donor's age and size. Recipients from such pairs will be suspended from the waiting list until either they will be transplanted or a incompatibility test will reveal that the exchange is not possible. List paired donation may increase the rate of transplants by expanding the donor pool. In such an exchange, an incompatible donor who will donate to a recipient from the waiting list while his recipient will receive a high priority for the allocation for a deceased donor kidney [43, 44]. There are several concerns regarding ethical and legal issues. Such a transplant is designed to give an alternative to O blood type recipients with a non-O incom‐ patible donor. The immediate consequence is the transplantation of a non-O blood group recipient from the waiting list and the addition of a O blood group recipient. This way, there will be an increased pressure over the O blood group recipients [43, 44].

Matching algorithms. Different matching algorithms were designed to maximize the number of recipients with an incompatible living donor will undergo renal transplantation. After an initial experience with two pairs, the number of pairs involved in a paired kidney transplan‐ tation increases to three, four and even more and the procedure gain worldwide acceptance. Involving of more than two pairs increases the chances to get a renal transplant but in order to avoid the withdrawal risk requires six or more operations to be done at the same time. Designed for O blood group recipients, exchanging of an incompatible kidney for a preferential position on the waiting list increases the recipient's chances for a renal transplantation but decreases the chances of other O blood group recipients from the waiting list [45-48]. This situation creates ethic dilemmas. Generalizing such list exchanges to any blood group recipient with a living donor available but incompatible, may overcome this issue.

Altruistic donation or non-directed donation is more ethical and legal challenging. It is difficult to believe and understand that a good Samaritan really exists and even when exists, national law framework should allow transplantation from unrelated living donor. Altruistic donors may be allocated to a waiting list or to initiate an open chain of paired transplantations [46,49]. Utilizing living donors may decrease the pressure for renal transplantation. Moreover, implementing of different types of kidney exchange could give further solutions to increase the transplantation rates. Combining different approaches to kidney exchange may create complex and versatile solutions to the incompatibility issue, even finding a better match for compatible pairs.

complications which were encountered in reconstruction of multiple arteries were graft thrombosis, stenosis of the renal artery, and an increased risk of reno-vascular hypertension [55-57]. The most frequently ureteral complication encountered [58] were ureteral necrosis and

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Smaller arteries are more prone to develop premature atherosclerotic occlusion. If that happens with a small accessory lower pole artery it would lead to ischemic distal ureteral stricture.

Any way, recent data collected from the centers and program of renal transplantation with experience in the field, display above any doubt that procurement of kidneys with multiple renal arteries can be accomplished safely and not impose additional medical, social, econom‐

Overall intraoperative and early postoperative complications of the recipients are not signifi‐ cantly different from the evolution of the recipients who received grafts with single arteries. A low rate of vascular complications is achieved using standard microvascular reconstruction technique with or without autologous vein patches [59-61] or extension graft. More than that, early graft function assessed by urine output and serum creatinine measurements were not significantly different among grafts with single arteries or grafts with multiple reconstructed arteries. In addition, long term quality of function, rejection, graft loss rates and graft survival were also similar. More than that, overall graft survival rates of this patients is exceeding 90%

In summary, the introduction of laparoscopic donor nephrectomy has significantly increased the number of grafts with multiple renal artery. Utilization of this donors, increase the rate of donation with 30% in specific centers. Modern techniques based on microsurgery have reduced dramatically incidence of above mentioned complications. From a patient outcome based perspective, this change in practice showed to be safe for both donors and recipients.

One great potential means for obtaining more kidneys is throw live donation. When compared with cadaveric renal transplantation, living donor transplantation has several advantages, in fact well known, which includes better graft survival, more rapid renal function after trans‐ plantation, shorter hospitalization and finally lower cost. However, several barriers exists for potential living donors. Significant time is involved when one donates a kidney. Many individuals do not have adequate financial and social support available that would allow them to make a personal sacrifice and a time commitment necessary for kidney donation. Moreover, the relatively prolonged convalescence can have significant financial impact on donor. Finally, fear of pain as well cosmetic concerns, associated with flank incision, can militate against

Laparoscopic living donor nephrectomy (LLDN) with all its alternatives (transperitoneal approach, retroperitoneal approach, hand assisted laparoscopic nephrectomy) was introduced

*2.8.2.3. Laparoscopic donor nephrectomy - alternative to increase the rate of living donation*

ical or postoperative clinical evolution burden, on the donor and the recipient.

pelvi-caliceal fistulas.

at 3 years.

kidney donation.

in 1995 by Ratner and Kavoussi [62].

#### *2.8.2. Medical methods to increase the number of living donation*
