**3.5. Conclusions**

During the last period of time, there was a spite of papers from individual countries and registries, which examined the ways in which the number of kidney donors could be increased. population is currently caring donor cards. No more than 50 donor per year results from this initiative. For the success of such schemes, continuous publicity is essential to increase optedin donors and transplant centers. Intensive care physicians and transplant coordinators should be mandated to access registry routinely, to identify the wishes of potential cadaveric donors.

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**Improved organization and resources.** Services must be more organized and better resourced to increase cadaver donation. In several countries, the number of intensive care beds is probably too low to achieve more than 20 donors per million from intensive care patients. In high donating countries, with better resourced intensive care units, the staff responsible for donation (transplant coordinators), have been expanded and given proper financial support. Transplant coordinators are also to be given the responsibility of public relations, with the aim

**Opting-out legislation.** The introduction of opting-out legislation appears on first site of the data available to be associated with the increased rates of cadaveric donation. In Europe, four countries which exceeded 20 kidneys donor per million population per annum, all have optingout legislation. In France however, opting-out legislation has not achieved such a successful donation rates. This may be because France choose initially, hard line opting-out, in which donation takes place if the donor has not opted-out irrespective of families wishes. Adverse publicity led to a softening of the practice, which consequently increases the donation rates. Other countries which presumed consent law practices soft presumed consent, in which the families are taking into account in all situations. In general, countries with informed consent do not perform as well, main exception being USA, where kidney donation rates exceed 25

**Criteria for donor suitability.** Non-heart beating donors (NHBD) are well known to produce a high rate of primary non-function and their acceptability was low. Recently introduced in situ perfusion of the dead bodies, which has been successfully developed in UK and Holland, are bringing in encouraging results. After harvesting, kidneys may be put into continuous perfusion machine, and their viability assessed using flow measurements and urinary and enzyme excretion. As a matter of fact, presumed consent legislation will allow more NHBD. Rapid intraarterial cold perfusion over recently deceased persons should be allowed before family consent low operate but perfusion without relatives permission is technically unwar‐ ranted assault. Agreement by a coroner should allow perfusion without permission and that

**Elderly donors.** Even if long term survival for kidneys from elderly donors (over 60 years old) is 10-15% less than those taken from younger donors, better results may be obtained with

A good quality organ must be guaranteed to the recipient and every transplant center must established its own guidelines on organ acceptability. If the transplant center uses a less than optimum organs from old subjects to expand the pool of donors, the donors must be evaluated according to age, vascular condition and renal function. The inferior limit for a single kidney transplant is considered creatinine clearance more than 60 mL/min. If the calculated creatinine clearance is between 60 and 50 mL/min. the donor may be considered marginal. If the calcu‐

carefully selected older donors and shortening of the cold ischemic time.

of avoiding adverse media publicity, and liaising with the coroners.

donors per million population.

could expand significantly NHBD.

Most studies examined single initiatives, such as changing the transplant law, rather than the development of integrated donor programs. The act of donation is a complex phenomenon depending on many factors and interactions, few of which individually have been proven useful or generally applicable throw the out the european community. Well designed studies are needed urgently. A donation is the result of a chain of events, the final result of which will depend upon its weakest link.

Even when the individual links have been strengthened, each element of the process of donation must be integrated into the operational policies developed in toon with national moral and cultural values. It is easy to set a minimum standard to which countries should aspire. But it is another matter to recommend specific, donor promoting activities for which individual countries and profesional organizational should aim.

Although, living donor rate are no increasing in Europe, rates could be further improved at different stages in the referral process:


Increase supply and use of cadaveric kidneys:

**Donor cards.** In many countries publicity schemes encourage the population to carry donor cards, or to register their wish to donate (opting-in) on a computerized donor register. Even if in UK 8 mil. of individuals are now registered in the opting-in computer, only 10% of the population is currently caring donor cards. No more than 50 donor per year results from this initiative. For the success of such schemes, continuous publicity is essential to increase optedin donors and transplant centers. Intensive care physicians and transplant coordinators should be mandated to access registry routinely, to identify the wishes of potential cadaveric donors.

**3.5. Conclusions**

depend upon its weakest link.

158 Current Issues and Future Direction in Kidney Transplantation

different stages in the referral process:

donor expenses allowed in law.

in a recommendation list.

Increase supply and use of cadaveric kidneys:

sale.

During the last period of time, there was a spite of papers from individual countries and registries, which examined the ways in which the number of kidney donors could be increased.

Most studies examined single initiatives, such as changing the transplant law, rather than the development of integrated donor programs. The act of donation is a complex phenomenon depending on many factors and interactions, few of which individually have been proven useful or generally applicable throw the out the european community. Well designed studies are needed urgently. A donation is the result of a chain of events, the final result of which will

Even when the individual links have been strengthened, each element of the process of donation must be integrated into the operational policies developed in toon with national moral and cultural values. It is easy to set a minimum standard to which countries should aspire. But it is another matter to recommend specific, donor promoting activities for which

Although, living donor rate are no increasing in Europe, rates could be further improved at

**•** Nephrologist at non transplanting as well as transplanting centers, should be encouraged to discuss openly the subject of living donation with family of patients suffering ESRD, preferably before the patient begins dialysis. This will results in predialysis transplantation, increased transplant rates, and is more efficient in case of reduced dialysis resources.

**•** Canceling facilities (e.g. by a senior nurse or living donor coordinators) should be available to discuss screening tests, provide information, and arrange eventually reimbursement of

**•** Each transplant center should work to an approved screening protocol, such that the

**•** If legally permitted, living unrelated donors should be encouraged. In many countries in Europe, altruistic non related kidney donation is allowed legally, provided that checks are made for altruistic motivation and exclusion as far as possible of the possibility of organ

**•** Non-directed living donor transplantation between altruistic donor and recipient unknown to the donor is possible and have been developed in few centers. Although controversial, there seem no moral or social reason to exclude such donors. However, there are ethical and legal concerns about this type of donation, which at the moment make it difficult to include

**Donor cards.** In many countries publicity schemes encourage the population to carry donor cards, or to register their wish to donate (opting-in) on a computerized donor register. Even if in UK 8 mil. of individuals are now registered in the opting-in computer, only 10% of the

predicted mortality risk of living donation does not exceed 1 in 3000 cases.

individual countries and profesional organizational should aim.

**Improved organization and resources.** Services must be more organized and better resourced to increase cadaver donation. In several countries, the number of intensive care beds is probably too low to achieve more than 20 donors per million from intensive care patients. In high donating countries, with better resourced intensive care units, the staff responsible for donation (transplant coordinators), have been expanded and given proper financial support. Transplant coordinators are also to be given the responsibility of public relations, with the aim of avoiding adverse media publicity, and liaising with the coroners.

**Opting-out legislation.** The introduction of opting-out legislation appears on first site of the data available to be associated with the increased rates of cadaveric donation. In Europe, four countries which exceeded 20 kidneys donor per million population per annum, all have optingout legislation. In France however, opting-out legislation has not achieved such a successful donation rates. This may be because France choose initially, hard line opting-out, in which donation takes place if the donor has not opted-out irrespective of families wishes. Adverse publicity led to a softening of the practice, which consequently increases the donation rates. Other countries which presumed consent law practices soft presumed consent, in which the families are taking into account in all situations. In general, countries with informed consent do not perform as well, main exception being USA, where kidney donation rates exceed 25 donors per million population.

**Criteria for donor suitability.** Non-heart beating donors (NHBD) are well known to produce a high rate of primary non-function and their acceptability was low. Recently introduced in situ perfusion of the dead bodies, which has been successfully developed in UK and Holland, are bringing in encouraging results. After harvesting, kidneys may be put into continuous perfusion machine, and their viability assessed using flow measurements and urinary and enzyme excretion. As a matter of fact, presumed consent legislation will allow more NHBD. Rapid intraarterial cold perfusion over recently deceased persons should be allowed before family consent low operate but perfusion without relatives permission is technically unwar‐ ranted assault. Agreement by a coroner should allow perfusion without permission and that could expand significantly NHBD.

**Elderly donors.** Even if long term survival for kidneys from elderly donors (over 60 years old) is 10-15% less than those taken from younger donors, better results may be obtained with carefully selected older donors and shortening of the cold ischemic time.

A good quality organ must be guaranteed to the recipient and every transplant center must established its own guidelines on organ acceptability. If the transplant center uses a less than optimum organs from old subjects to expand the pool of donors, the donors must be evaluated according to age, vascular condition and renal function. The inferior limit for a single kidney transplant is considered creatinine clearance more than 60 mL/min. If the calculated creatinine clearance is between 60 and 50 mL/min. the donor may be considered marginal. If the calcu‐ lated creatinine clearance is less than 50 mL/min. than the kidney should not be used for a single transplantation, however, as they are organs that nobody wants they can be used for dual transplantation. When this policy is established, it is necessary to inform the patient on the waiting list.

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